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f J 7 , APPLICATION FOR PERMITR EXEE SAN JOAQUIN LOCAL HEALTH DISTRICT V E. Dd, 1601 E. HAZE T ON AVE., STOCKTON, CA NOV 3 0 � 9 Telephone 12091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIROMMIM dITAL HEALTH (Complete in Triplicate) PER M 1 • SEV;CwS ' Application is heteby 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 Health,District Job-Addres's 30 31 r„L 1 n n.e Rd ' City T r a c Lot Size PM Owner's Name O r m o n d e Development Address 40,j BOX 1009 , Tracy Phone 82 5- r Contractor Hennings Bros . Addre4525 Pet'andaIe , Mad . License No. 290813 Phone_54 5- TYPE OF WELL/PUMP: NEW WELL 11 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100 , SEWER LINES DISPOSAL FLD. 1 a 0 r +PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 2 1I pia. of Well Casing 6 " rH+Domestic/Private XIX Gravel Pack XLX Tracy Type of Casing PVC Specifications i'] Public ❑ Other ❑ Delta Depth of Grout Seal 10 0 Type of Grout Bentonite I I I irrigation A_1*Approx. Depth I I Eastern Surface Seal Installed by d r i l l e r Repair Work Done ❑ Type of Pump H.P. State Work Done k Well Destruction ❑ Well Diameter Sealing Material [top 50') r Depth Fillet Material IBolow 50') M k4,n TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is A 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 r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size 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 drawin o reverse ' Signed > e n n i n g s Bros , By Tit! : Date: 11 -29-89 J FOR DEP T T USE ONLY [� Application Accepted by _ Date �+ Area--2/1 Pit o Grout nspection by w DatFinal Inspection by Date Additional Comments ❑ Stk 466-678t ❑ Lodi 369-3621 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. �.EH t3-24{gEV.i/,1E;� 37 p^-f'f• _ � EH 14-Ze r tp f