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APPLICATION FOR PERMIT n: f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) k 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 aOrdinance No. 549 for sewage or No. 1862 for welU pump and the Rules and Regulations of the San Joaquin Local Health District = 125'x348' PM 8197„ W Li..nne' Rd. city Tracy - Lot 52e ' Job Address <- _ _ I J.D. Most Const. Address 3941 H011 Dr. #A TRac Phone 835-6-921 Owner's Name l Contractor Henn i n s Bros. r Address 3525 Pel anda l e, Mod. License No. 290813 Phone 545-1185 I[ TYPE OF WELLIPUMP: NEW WELL ( WELL REPLACEMENT ❑ DESTRUCTION ❑ e PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK 100' SEWER LINES DISPOSAL FLD. 100'. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS __ INTENDED USE TYPE OF WELL PROBLEM ARREAR CONSTRUCTION SPECIFICATIONS 6n ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation .2n Dia. of Well Casing Type of Casing Specifications HDomestic/Private gnGravel Pack `Tracy yP Bentonite I'] Public CI Other F1 Delta Depth of Grout Seal t Type of Grout - I ! Irrigation __Approx. Depth l I Eastern Surface Seal Installed by rill Cal" I H P. State Work Done Repair Work Done ❑ Type of Pump Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth 2.20Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION I I avlo septi ailable cystithin m permitted it public sewer is Installation will serve: Residence Commercial— Other fNumber of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mig Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t � SEEPAGE PITS I I Depth 'I Size Number k SUMPS L1 Distance to nearest: Well Foundation Property Line ..DISPOSAL PONDS_ ❑_ ,r �- _z. -.:T -== �-� - - --==z 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. ify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I cert employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 loy persons subject to workman's compensa- tion laws of California." I P The applicant must call for all required inspections. Complete drawing o verse sid . Signed X Hennings Bros. Title: Date: 12-5-90 l FOR DEPA USE ONLY Application Accepted by Date / Area �/ol Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ��- ��9' C-4t ❑ Stk 466-6781 ❑ Lodi 369-3621 © Manteca 823-7104 ❑ Tracy 635-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2N 900 , Stk., CA 95201 FEE I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO ? ..EH 13-24 IREV.1/H 5Y EH 14-28