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n - K w 7 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT "' ILE " 1601 E. FtAZE:.TON AVE., ST.00KTON, CA �j Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED 3 (Complete in Triplicate) Application is heisby 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 sawige or No. 1862 for well/pp and the Rules and Regulations of a San Joaquin Local Health District. Ii �/ �( �9� �� ZjrLt —zp� N.W. corner of Milton Rd. & Escalon- Belty ot Joh Address Cia,H / Lot Size Owner's Name Edward Rainey Address 76 Palm Dr., Union City Phone415--484-2275 l Contractor Hennings Bros. Address3525 Pel'andale, Mod. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL n WELL REPLACEMENT ❑ DESTRUCTION ❑ PUM� INSTALLATION ❑ S TEM REPAIR ❑ OTHER ❑ y DISTANCE TO NEAREST: SEPYIC TANK. none SEWER LINES, _ DISPOSAL FLD. PROP. LINE _ .--aF„• .rte,.._• _ FOUNDATION AGRICULTURE WELL OTH W Lt* PIT /SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing V. NtDomesticl Private XX Gravel Pack ❑ Tracy Type of Casing PVC Specifications Fl Public C1 Other !3 D 1 a Depth of Grout Sealy Type of Grout Bentonite F I i Irrigation ,3�to ``(dp J� s J ..A pro pth �1 Eastern ' Surface Seal installed by driller _ Repair Work Done ❑ Type bf Pump H.I". State Work Done_ Wetl Destruction ❑ Well Diameter Sealing Material(top 5011 N Depth Filler Material JBalow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is I available within 200 feet-) Installation will serve:` Residence_. Commercial— Other 1 ` Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ I. Method of Disposal Distance to nearest: Well Foundation Property Line t it LEACHING LINE 0 Nd.&Length of lines Total length/size `FILTER BED O Distance to nearest: Well Foundation Property Line t SEEPAGE PITS I 1 Depth Size Number r, �SUMP5 L1-;Dto_neares�,' -_1 _•�F,ound8tiosn __ _property ane - 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 SantJoaquin Local Health Di§trict. \\ Home owner or licensed agent's signature certifies the following: "t 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 became subjectto workman's compensation laws of California."Contractors 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 parsons subiect to workman's compensa- tion laws of California." G t The applicant must tail for all required inspections. Complete drawin reverse sid l\ Signed X Henn in s Bras. By Tie Date: 7--2590- OR D MENT USE ONLY Application Accepted by Date t ` 0 Area r 'S I Pit Grout nspection b Date Final Inspection by / Data P� Additional Comments: t3 L C�►`� �, r�{o r �� ❑ 5tk 466-6781 ❑ Lodi .369-3621 ❑ Manteca SM-7104 ❑ Tracy 6385 f/��y�By -1 ' Applicant- Return all copies to:frivironmentai Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201z+ef y-l7 Ipl Cg 0)1t6FEE •-. /3-i.� s. Q�*Jr -- it-tel ! INFO AMDUtET DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. v 1 ♦.04 3-24 IItEv.s/n 57 q o Eti tt-Ig II �