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7 ^��. . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 466-6781 PA f PERMIT EXPIRES I YEAR(209) *ZCy Z FROM DATE ISSUED veo (Complete in Triplicate) OCT 19 �t188QQ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the 'n described 9M'3 application is made in compliance with Sen Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rul �it of the San Joaquin Local Health District. - PFR4,11T�SFRV FSALTy Job Address 11495 Van Al len Rd. Cay Esca Ion Lot Size PM Owner's Name _QUI"Val Gornes Address 11495 Van Allen ES alon Phone 838-1549 Contractor HenninaS Bros Address 3525 Pelandale Plod License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL kA WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION❑ -- SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK 100 1 SEWER LINES DISPOSAL FLD. 10111 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 dI Domestic/Private IX Gravel Pack ❑ Tracy Type of Casing PV Specifications Public ❑ Other n Delta Depth of Grout Seal 501 Type of Grout Bentonite I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ dri I I r _ Repair Work Done ❑ Type of Pump H.P. State Work Done ., Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I IREPAIR/ADDITION 1 I DESTRUCTION 1 1 (No se tics stem P Y permitted i1 public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms t (\ Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth V 1 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑: + . Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and `t rules and regulations of the San Joaquin Local Health DiRtrict. Home owner or licensed agent's signature certifies the following: "1 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."Contractoes 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 drawin rev se side. Signed x Hennings Bros Title: �l/ Date: 10-17-88 FORO-EPA$/jMEN ONLY ^L f� Application Accepted by /L �—��--- Date — J _�o AreayS Pit or Grout Inspection by .��w..� nar„��d7 Final i„____,; ) - on by ^ Date ; /,- ;7 Additional Comments: x'✓// iYj d ,U+ryz /"e ❑ Stk 466-6781 Cl Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Servloes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED �/} ASH RECEIVED BY DATE EH PERMIT'NO. a. 11].IREV.r/x51 a��p ' EH 1420` /