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APPLICATION FOR PERMIT ;, SAN JOAQUIN LOCA. HEALTH"DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA eAYMIL'M "` Telephone {209} 466-6781 RECEIVET� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED !Complete in Triplicate? JUL �g�Q Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work b �Ac�t e r made rn,compliance with San Joa wn Court ordinance No ��e�!� ��" q t1 549 for sewage �i��(�1etI Y ffi4l b'a�ion rs Loc2I Health [7�strrct y 1:I a tti 9 or No. 1862 for well/pump and the Rules and RegLlfdtl4i��eflt}�� oJoaquin Job'Address" 9350 Hi ldretl ,.;Rd:.. Stockton Lo City t Size PM Owner's Name Norman Nock Address 9350 Hildreth, Stockton Phone 931-4710 d54585 Contractor._ Hennings Bros. Address 3525,'Pelandaie, Mod. TYPE OF WELL/PUMP: NEW WELL License No. 2908N Phone_ WELL REPLACEMENT DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ n = - —12�__ SEWER LINES DISPOSAL FLD.�-�_ PROP. LINE FOUNDATION —AGRICULTURE WELL OTHER WELL_-_pITSLSUMP_S..INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ofWell ExcavationDomestic/Private _ Dia. of Well Casin Gravel Pack ❑Tracy Type of Casing PVC ❑ Public n Other specifications f {� Delta Depth of Grout Seal 5O 1 ` I I Irrigation Type of Grout Bentonite _ _._Approx. Depth 1 l Eastern Surface Seal Installed by driller Repair Work Done ❑ Type of Pump H P State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') F Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.) REPAIR/ADDITION I IDESTRUCTION [ I (No septic system permitted if public sewer is ' Installation will serve: Residence— Commercial— Other available within 200 feet.! �W Number of living units: i Number of bedrooms V ! F Character of soil'to a depth of;3, feet: SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Distance to nearest: Well "' Foundation Method of Disposal J- Property Line LEACHING LINE ❑ No.'& Length of lines [� FTotal length/size FILTER BED ?� ❑ Distance to nearest: Well Foundation Property Line - Y . - SEEPAGE PITS I i Depth Size �-^•- -SUMPSNumber- ---- Ll Distance to_nearest: - _Well _ _ Foundation DISPOSAL PONDS ❑ .Property_Line_, 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 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 required inspections. Complete drawing on reverse side. Signed x HenningS Bros. 7-26-90 Title: Date: f FOR EPA MENT USE ONLY Application Accepted by / Date .- Area Pit or Grout Inspection by Date Final Inspection by Date } Additional Comments- �.- ❑ Stk 466-6781 p Lodi 369-3 _ Manteca 823-7104 ❑ Tra 835-6385 �( r Applicant- Return all capias to: E onmental Hea Permit/Services 1601 E. Hazelton Ave., P.O. �9 Box i k.. CA 95201 lY FEE AMOUN UE / r ' INFO 4 T REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24/REV.r i x 51 (41 EH 14-28 Jp 4 V -70 qL V a�f