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a APPLICATION FOR PERMIT <br /> E � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> 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 <br /> Local Health District. lav o (��'✓�.5 Avg r <br /> Job Address 30000 S. Garden Ave. City Manteca Lot Size PM <br /> Owner's Name Ormonde Development Address P .O. Box 1009 , Tracy Phone 835-7990 <br /> Contractor Hennings Bros . Address 3525 Pelandale , Mod.LicenseNo. 290813 Phone 545-1185 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 100 , SEWER LINES DISPOSAL FLD. 10 0 t PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom (Manteca Dia- of Well Excavation 1 P It Dia. of Well Casing It <br /> 7 <br /> Domestic/Private IX Gravel Pack C Tracy Type of Casing Specifications <br /> f'1 Public ❑ Other ❑ Delta Depth'of Grout Seal t Type of Grout-!an t o n i t e <br /> I I Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by d r 1 I I e r _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLA- � - ?ptic system permitted if public sewer is <br /> / ble within 20D feet.) O <br /> Installation will serve: Residence_ Cc /�� �/ 0 <br /> Number of living units: Number of l� � 0 <br /> Character of soil to a depth of 3 feet. _ �yfEd�y��� ' Water table depth 0 <br /> SEPTIC TANK ❑ Type/Mfg _ 6 /`.�S f�� � f No. Compartments . <br /> PKG. TREATMENT PLT. 171 . Alv `! Method of Disposal <br /> Distance to net ty Line r <br /> LEACHING LINE ❑ No. & Length t size <br /> FILTER BED ❑ Distance to net :rty Line <br /> SEEPAGE_ PITS l I Depth <br /> SUMPS Ll 5istance to ne my Line --- <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this appl to Joaquin county ordinances, state laws, and. - <br /> rules and regulations of the San Joaquin Loc <br /> Home owner or licensed agent's signature cei work for which this permit is issued, I shall not <br /> employ any person in such manner as to becc contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the perturmance-DTmeorrc or wniia"�c'' ploy persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing averse s' ' <br /> Signed X Hennings Bros . By Title- Date: 4- 12-90 <br /> FDR DEPA M T USE ONLY <br /> Application Accepted by Date Area <br /> Pito Grotit l spection by Date�'`ra Final Inspection by Date <br /> Additional Comments: G �ot4 t C—; L d f { <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Ma teca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13.241REV.i/H51 <br /> EH 14-2e r l� O ho ' QS <br />