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Uv APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T 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 compliance with San Joaquin County Ordinance No,549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin I Local Healfh"District.t Ca-3tNo� �S'r. �k east side Job Address `. Flshback Rd.-=1/4mi. south of Hwy__i20 City Mante^c-a— -__ Lot Size PM City of Manteca Owner's Name W Address Phone 486-8733 ' Hennin s Bros. 3525 Pelandale, Mod. License No. 290813 Phone545-1185 ) Contractor g Address ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION DO Abandonment PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE " i- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS II ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well CasingI ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('l Public Ll Other Ll Delta Depth of Grout Seal Type of Grout-- 7 I I Irrigation .-Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done_ s Well Destruction ( Weil Diameter , 611 Sealing Material (top 50') — \ }' y Depth �� Filler Material I Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is r j ' V available within 200 feet.) , C Installation will serve: Residence— Commercial— Other };kr, Number of living units: Number of bedrooms Character of soil to aidepth of 3 feet: Water table depth SEPTIC TANK ❑ Type/MfgCapacity 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 ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS l I Depth Size Number SUMPS D 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 drawing on erse sid . Signed x Hennings Bros. By Title: Date: 8-2-90 FOR D PART ENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date - I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMI-r'NO. EH 13-24 IR EV.ti n5) a0 ^1, 3 � 0_Ig7+5 r EH 14-26 ��ro