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. '" '`' APPLICATION FOR PERMIT °��3 *, SAN JOAQUIN LOCAL HEALTH DISTRICT z 1601 E. HAZE T ON AVE., STOCKTON, CA ; Telephone (209) 466-6781 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 corripliance ltiith San JoIt in County O�rdinance-No 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local }9ealtK`District. I 3140 S'., Kasson' Rd'. City Tracy __ Lot size PM Job Address f Owner's Name _0rmonde ':D pinerlt_ Address Phone 835 4949 Contractor I Address License IVO,290813 Phone 5453185 TYPE OF WELL/PUMP: II NEW WELL WELL REPLACEMENT 71 DESTRUCTION ❑ PUMP INSTALLATION L) SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE-.TO NEAREST- SEPTIC TANK 100' SEWER LINES �-QOt--.-�- PROP. LINE t y - FOUNDATION �.W DISPOSAL FLO.AGRICULTURE WELL -`"'�OTfiER WELL=--'PIT5-/SUMPS-��--- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial. ❑ Open Bottom L] Manteca Dia. of Well Excavation_ 12 Dia. of Well Casing rr /LT Domestic/Private H Gavel Pack Ax Tracy Type of Casing Specifications [IPublic C1 Other L1 Delta Depth of Grout Seal Type of Grout BLntan i to _. `I I Irrigation J�-Approx. Depth I. I Eastern Surface Seal installed by Repair Work Done L1Typle of Pump H.P. State Work Done _ els Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 5011 O I TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) 'IIS � ' Installation will serve: Residence_ Commercial_ Other. Number of living units: I� Number of bedrooms ` Character of soil 10 a depthil f 3 feet: Water table depth T 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 I� SEEPAGE PITS Ill ,IDepth Size Number SUMPS ❑ istance to nearest: Well Founaation �- Property-Line DISPOSAL PONDS ❑ 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 S.an Joaquin Local.Health District. Home owner or licensed agen'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." h� r The applicant must call for affrequired inspections. Complete drawing on rave e. Signed X Henningsllbros. Title: BYL Date: 7-28'$9 FOR DEPARTMENT SE ONLY Application Accepted by Date �f Area Pit or Grout Inspection by Data Final Inspection by ate 4 /3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 69-3621 ❑ 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. µ INFO r.EH 13-24(REV.1)K51 /O. UD �Q .()U �j� ~�� l �� tel - EH 14-26 /h „