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w <br /> i <br /> i <br /> APPLICATION FOR PERMIT <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t <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 j <br /> Local Health District. I <br /> . 4 <br /> Job Address 3501 W. UNDINE RD . cit. S T O C K T O N Lot Size PM <br /> 1 <br /> Owner's Name LLOYD PHELPS Address 3501 W . UNDINE RD. Phone 462-5994 <br /> Contractor HENNINGS BROS. Address 3525 PELANDALE AVE. License No. 2901 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION)P( <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I <br /> Cl Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation —.-Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done <br /> Well Destruction 1X Well Diameter Sealing Material (top 50) BENT 0 N ITE PPPPF I I F T S <br /> Depth 70 t Filler Material (Below 5o,) BENTONITE PELLETS <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION I I {No septic system permitted if public sewer is <br /> available within 200 feet.) + <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total len th/size <br /> r <br /> 9 9 , <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS L� Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin Local Health Di§trict. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawingreverse side. <br /> Signed x H E N N I NGS B R 0 S__ 0 RI LL I NG_ BY Title: Date:J U N E 12 • 1991 <br /> i <br /> FOR DEPART NT USE ONLY <br /> Application Accepted by ao, <br /> Date W -94 Area / 4 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-67$1 ❑ Lodi 369-3621 ❑ Manteca 523-7164 ❑ 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 /> r, <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK 11 CASH RECEIVED BY DATE ppPERMIT"NO. <br /> +.EH 13-24 IREV.i i n e) - M _ _ M©� f l—W —f, <br /> EH 14-26 • V v V' r'f 1' <br />