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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 11651 Palm Lane city R1 0� n Lot Size 20 Acr s± PM Owner's Name Southwest Hide CO. Address P.O. BOX 2083- Manteca. CA Phone 2091599-4251 Contractor_ Hennings Brothers Address 3525 Pelandale Ave. License No. 290813 Phone 20_ 9/545_118 TYPE OF WELL/PUMP: t�or NEW WELL EX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100'± SEWER LINES 100'± DISPOSAL FLO. 100'± PROP. LINE100'± FOUNDATION 50'± AGRICULTURE WELL 10W±OTHER WELL 100'± PITS/SUMPS 50'� ± INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial R3 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 611 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Specifications ❑ Public X1 Other ❑ Delta Depth of Grout Seal 5' Type of Grout Concrete ❑ Irrigation 3�+n pprox. Depth EJ Eastern Surface Seal Installed by Contractor Repair Work Done ❑ Type of Pump N/A H.P. _NZA State Work Done NZA Well Destruction ❑ Well Diameter 611 � Sealing Material Itop 50'1 Concrete l` Depth 301 ± Filler Material (Below 501 Sand TYPE OF SEPTICWORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet. Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 q 'ed inspections. Complete drawing on reverse side. r Signed Title: Manager Date: 5 September 1986 ana ans R DEPARTMENT USE ONLY Application Accepted Date Area 40 Pit or Grout Inspection yDate Final Inspection by e .�C�- Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO C EH13-24(REV,1 8 5) C 0 0C EH 14-26 �J � X�J