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(pe APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT } 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. l/Ffr Job Address corner of 1-i nnpCnrrai__Hol i ow City TRACY Lot Size PM Owner's Name REST Rl OCKS ,l Address Phone r a — Contractor HENNINGS BROS, DRILLAddress License No. 290513 Phone545-118-5 TYPE OF WELL/PUMP: NEW WELL}(X WELL REPLACEMENT ❑ DE=STRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK: 100'4- SEWER LINES 100'4- DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Vs u Dia. of Well Casing rr IX Domestic/Private CIQ Gravel Pack �x Tracy Type of Casing STER Specifications D } E`7 Public Cl Other F1Delta Depth of Grout Seal ino, Type of Grout NEALCEM I I Irrigation —..Approx, Depth I I Eastern Surface Seal Installed by H E N N I N GS BROS . DRILLING i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 I Depth Filler Material I8elow 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 1 : available within 2DO feet.) p Installation will serve: Residence_ i Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ i 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 3 SEEPAGE PITS I 1 Depth Size _ Number I SUMPS 0 Distance tornearest: Well Foundation Property Line ` DISPOSAL PONDS ❑ r 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. f 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 ddrr�a/ in reverse si . Signed X . Tit Date: FOR DEPARTMENT USE ONLY f_ Application Accepted by i Date rea Ir/ Pit or Grout Inspection byDate Final Inspection by to I Additional Comments: 101Z—los " ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE "t AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. +.EH111-28 3-21IREV.1/Hsl EH ®Q �� 743