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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 !PERMIT EXPIRES YYEAR 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 Heaiih bistrict 3" `' r.* ;r:• 1 { Y ],�/ �14�i I Finn PM t .Job Address 6700 Jadktone.RC1 J v t " City Lot Size Owner's Name Kuipers Construction Address 336 W. 2nd St. , Ripon Phone 599-3946 Contractor Hennings Bros. 3 Address License No.�9�$13,____Phone – TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 60' SEWER LINES DISPOSAL FLD.60'+ PROP. LINE FOUNDATION-- "AGRICULTURE WEL-LOTHER WELL " ,PITS/SUM PS_. ,r �4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12" Dia. of Well Casing 6'� N Domestic/Private K1 Gravel Pack ❑ Tracy Type of Casing PVC Specifications M Public 1-1 Other Cl Delta Depth of Grout Seal 501 Type of Grout BentOn rte I I Irrigation —..Approx. Depth Il Eastern Surface Seal Installed by driller i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 — "�—:,,TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I ) DESTRUCTION l I INo 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 SEEPAGE PITS I I Depth Size Number SUMPS __ –: . . Cl_ 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 D3trict. 7 d 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." Cf� The applicant must call for all requited inspections. Complete drawing on rsa side. Signed X Hennings Bros. Title: Date: 6-27-90 FDR DEPAR i1i NT USE ONLY '`� 15- Application Accepted by Date / d Area Pit or Grout Inspection by Date 7 �1.150 Final Inspection by Date Additional Comments: J ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 It Tracy 835-6385 j Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT REMITTED <09� RECEIVED BY DATE PERMIT*NO. INFO AMOUNT DUE CASH . EH13-241REV.i/n51 -7 Cly EH 14-26 0 l