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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT, r r �%l [� 1601 E. HAZEL i ON AVE., STOCKTON, CA RECEIVED W 6 ( �J" Teiephane 12091 466-6781 Y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY 2 51988 (Complete in Triplicate) ENVIRONMENTAL a SALT! Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desc1&*#A1 11 1 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 a an oaquin local Health District.6�—— Z Job Address Lot 91 r1P-COUr1 — city Tr-aC Lot Size PM Owner's Name Delta D6.._Company Address P.0—Roo 7414 CTO-cktnn ___ Phone 474-9922 Contractor Hennings ngz5 Bros_ _Address ,3-5?r) Pelaada l P. Mad_ —Li License No, _-2Q081-3--Phone TYPE OF WELL/PUMP: " NEW WELL -WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK 100' SEWER LINES DISPOSAL FLD.I PROP. LINE 60-1— FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Ria- of Well Excavation 1.1 Dia. of Well Casing Oil Domestic/Private Q Gravel Pack E)(Tracy Type of Casing PVC Specifications M Public f7 Other 0 Delta Depth of Grout Seal 100 . Type of Grout Bentonite 1 Irrigation -Approx. Depth I ) Eastern Surface Seal Installed by driller _ Repair Work Done ❑ Type of Pump H.P. — State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 , Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l_I DESTRUCTION ( I-(No septic system permitted if public sewer is 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 LEACHING LINE ❑ No. & Length of lines,.. Total length/size FILTER BED ElDistance}'to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L7 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." ! Y The applicant.must call for all required inspections. Complete drawing cin/Erse 7%U-,Z1, Signed X Henngs Bros By Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date OArea i Pit or Grout Inspection by DFte �y Final Inspection by Date Additional Comments: r, QP oto.! Z ❑ Stk 466-6781 ❑ 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 kFEE AMOUNT DUE' AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. a.EH 13-24IREV.1/1151 EH 14-26