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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 compliarice 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 Address 6086 W• L i n n e Rd. City Tracy .__ Lot Size2 4 0 I x273 PM Owner's Name O r m o n d e D e v e l o m e,n t Address P . 0. Box 1009 , Trac Phone 835-7990 Contractor Henr1i11 5 bras . -Address 3525 Pelandale Mod .L,IcenseNo. 290813 Phone-545-1185 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLAT t❑ SYSTEM REPAIR ❑ O" ER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD? � f 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 Dia. of Well Casing 6" X1 Domestic/Private XL7 Gravel Pack X1 Tracy Type of Casing PVC Specifications (l Public ❑ Other Cl Delta Depth of Grout Seal 1 0 0 I Type of GrouP e r1 t on i t e I I Irrigation _Approx. Depth 11 Eastern Surface Seal Installed by d r i l l e r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter —7 __- Sealing Material {top 501 Depth o7/p Filler Material (Below 50'I _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is fl 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 G SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments L 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 i SEEPAGE PITS [ I Depth Size Number SUMPS_, �, ❑ �Distance to nearest: Well Foundation p — _ 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: 1 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 drawinWME si Signed XHennings Bros . B Title Data: 4- 12-90 I° FOR DEPSE ONLY �� I Application Accepted by Date rea Pit or Grout Inspection by at Final Inspection by to Additional Comments: 6z7 ❑ Silk 466-6781 ❑ Lodi -3621 ❑ Mante 823-7104 01❑ 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 REMITTEDcrcKy INFO gH RECEIVED BY DATE PERMIT NO. +.EH 1324(REV.r/H 5) — ./.�r� EH 14-2e / CJ —f