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I APPLICATION FOR PERMIT' SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZE T ON AVE., STOGKTON, CA PAYMENT" Telephone 1209) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AEC 15 198 I (complete in Triplicate) nnee//�� t Tv Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work >�19�+ N dr/xoc�n is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules�JgkkTU MAV. zroaquin Local,Health District. ENVIRON ENTAL HEALTH DIVISION � w Job Address 606 2 W " L i n n e R d . City Tracy Lot Size PM Owner's Name 0rmonde DeveIo merit Address P.O.. Box 1009 , 'Trac Phone 835-4949 I Contractor Hennings BRos. Address 3525 P e I a n d a I e Modl.icenseNo. 290813 Phone 545-1185 k TYPE OF WE NEW W ELIA WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LJOTHER ❑ —DISTANCE TO NEAREST: SEPTIC TANK 100 , SEWER LINES DISPOSAL FLO. 10 0 1 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER,WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation 1 rr Dia. of Well Casing u l omestic/Private �,f--y Y 9 � x�Gravel Pack /C_/�TraC Type of Casing Specifications M Public ❑ Other Ll Delta Depth of Grout Seal 100 f Type of Grout R e n tani_ e_-, i I Irrigation _..Approx. Depth I 1 Eastern Surface Seal Installed by rirl.i j Ar Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 — 1 TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIRIADDITION l I DESTRUCTION l I Wo septic system permitted if public sewer is d available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ,1 Number of living units: Number of bedrooms 1� 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 s Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS l I Depth Size Number SUMPS L1 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 Di1trict. 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 a persons subject to workman's compensa- tion laws of California." , The applicant must call for all required inspections. Complete drawing r ve 7LX,1_Zd1D Signed x Hennings Bros . By Title. Date: 12-15-89 FOR DEPA USE ONLY Application Accepted by Date ✓ Area r Pito Grout nspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Ef Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 k Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO CASH EH 13-24(REV.1/N5] �© 4-'I � - �,.'3ciss EH 1426 t. �r