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t r 3, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT emerge"n cy- Family out of 1601 E. HAZE i ON AVE., STOCKTON, CA water- No neighbors to get Telephone (209) 466-6781 water from ; 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 14250 Grimes Rd. city Tracy Lot Size PM Owner's Name Bert BaCChettl Farms, Address 11104 trf_ Tracy R,,.__1vri_TTrary Phone 835-2924 Contractor Hennings Bros, Address 35255 Pelandale, Modesto License No. 290813 Phone-545-1185 TYPE hone_ 4 — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT A DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 2001 SEWER LINES DISPOSAL FLD..20 1_-E.. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 2O t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of-Well Excavation 1211 Dia. of Well Casing 611 IX Domestic/Private IN Gravel Pack 10 Tracy Type of Casing PVC . Specifications i`i Public Cl Other ❑ Delta Depth of Grout Seal 50, Type of Grout Bent0nit-12 I 1 Irrigation _..Approx. Depth I I Eastern Surface Seal installed by drl I 1 pr Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 N TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted it public sewer is available within 200 feet.) Installation.vOl 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 SEEPAGE PITS I 1 Depth Size Number SUMPS L1 Distance to nearest: Well 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 Diltrict. 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 drawing on reurerse side. Signed X Henning,, RrnS_ RV — Title: , Date: 10-25-88 FO PARTMENT USE ONLYryioY, Application Accepted by // Date 6z Area Pit or Grout Inspection by Date .<t� Final Inspection by 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 INFO AMOUNT C6 TUE AMOUNT RE.�MTI�TTED C SH RECEIVED By DATE PERMIT NO. +.EH 13-24 fREv.1/N 5) O `r / )�✓ EH ta�2a