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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'f'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install'the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Loco! Health District. ., _ Apricot Acres Subdivision, Job Address —ZB[�zS Traina Ct. L0t #g1 City Tracy Lot Size - PM Owner's Name Wi 1.1 iam Edwards Address 6352 Phone835-4651 ContractorHp rings Bros. ____Address 3525 Pelandale Mod. License No.—29L$A.3_..vPhone -1185 TYPE OF WELL/PUMP: NEW WELL IX WELL REPLACEMENT ❑ DESTRUCTION ❑ x PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. 1001____ SEWER LINES DISPOSAL FLO. 10&1.1PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE - TYPE OF WELL PROBLEM AREA° CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation ° Dia. of Well Casing IX'Domestic/Private y KI Gravel Pack Tracy Type of Casing PVC Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal 100, Type of Grout _ 1 ! Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by dri l ler Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRYADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of riving units"�- Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth 0 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well r _ foundation 'Property Line N LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation .Property Line I SEEPAGE PITS 11 Depth Size ° : Number SUMPS ❑ Distance to nearest: Well t Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:,"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit,is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawl on aide. ' Signed X Hennings Bros_ By ___ Ti Date: 6-26-89 FO D TMENT USE ONLj Application Accepted by Date -Area Pit or Grout Inspection by Date Final Inspection by i Date ' -Additional Comments: r 6v� 5� ©`/ CJ ❑ Stk 466-6781 ❑ Lodi -3621 Mant ca 823-7104 .❑ Tra4 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I7` S&4 Lw , FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO, INFO f.EH 13-24(REV.i i H 5) EH 14-28 f