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*per APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 MAY 2 5 19H PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTFFF Application is hefeby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descr wisgividisis 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. Lot 16 N.W. Corner of u i� r vcy > airoak�of�I Forn3seero estates Job Address ize P Owner's Name Delta DeV. Company Address ^ Phone 474-9 22 Contractor Hennin s Bros. Address License No. 2q08J3 Phone 85 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100'. __ SEWER LINES DISPOSAL FLO.11710' PROP. LINE mgt FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i' Dia. of Well Casing 11 A Domestic/Private ill Gravel Pack X] Tracy Type of Casing Specifications 1-1 Public ❑ Other 71 Delta Depth of Grout Seal 112bType of GroutBerson i t.e __. I I Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by fi r i 1 ler Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t 1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms_ 7 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 Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Siza Number SUMPS ❑ 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 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 o reverse Ida, Signed X Hennings Bros. By Title: Date: 5-23-88 FOR DEPARTMENT tE ONLY Application Accepted byy Date SL_aArea C) Pit or Grout Inspection b Date( � ry Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ 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 /05-1111 FEE INFO AMOUNT DUE AMOUNT�RlimiTTED CK RECEIVED BY ^DATE PERMIT'NO. eASlf +.EH t32R IREV. EH 11/"51 -7V. �ID r7O, tet✓ oWgI v S pC7��j� ^13� 929