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Y APPLICATION FOR.PERMIT SAN JOAQUINIOCAL HEALTH DISTRICT 1601 E. HAZE,--i ON AVE., STOCKTON, CA Teleph6ne (209) 466-6781 -6 9AR�,'P! RIlOM- _.LDAT1E ISSUED PERMIT EXPIRESY 10-.--,,(Complete in Triplicate),., , Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here-in'des"cr6d.,Thiii'a0plication is made in-compliance with San Joeuinzounry-Ordinance.No.549 for sewage or-No. 1862 for well/pump and the Rules and Regulations of the San Joaquin q Local Health e e C vl r7i !, � _; �wl&'Jr� �d. 'Fr'onta96 Lodi Job Address South of..'21 "Lawes r_ Lot size 120x200PM C,1_ty_-_0,f�-c6di Ca 1`1`:Bqx�'5006 3W L-§7 0 6' Owner's Name Address Phone Contractor's Name Henn i ng Bros -_ License No. 29081L Phone: 545-1185 TYPE OF WELL/PUMP; NEW WELL 171 WELL REPLACEMENT 1:3 DESTRUCTION 0 PUMP INSTALLATION 0 SYSTEM REPAIR 1:1 OTHER z,- Test Well DISTANCE TO NEA.REST. SEPTIC TANK -0 SEWER LINES 500 DISPOSAL FLb. 0 PROP. LINE.—A-V FOUNDATION ----5-0- AGRICULTURE WELL OTHER WELL_.._.-- PITS/SUMPS INTENDED USE, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial Open Bottom 0 Manteca Dia. of Well Excavation L 611 Dia. of Well Casing 0 Domestic/Private El Gravel Pack 0 Tracy Type of Casing Specifications 0 Public itl Other C1 Delta Depth of Grout seal 7 Type of Grout 0 Irrigation 50OApprox. Depth LJ Eastern Surface Sea] Installed by Repair Work Done 0 . Type of Pump H.P. --- State Work Done :Well Destruction El - Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION C1 iNo 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 0 -Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE E71 No. & Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line SEEPAGE PITS C Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS 0 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 Son Joaquin Lodal Health District. Horne 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 alUequired inspections. Complete drawing o reverse side. VP C Ir AL Signed Title: ..............0 Date: FOR DEUARTMENT USE ONLY Application'Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: 0 Stk 46&9781 0 Lodi- 309-3621 EI Manteca" 823-7104 - 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA FSMI FEE -AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT,NO. INFO CASH 7' +EH 13-24(REV 0 EH 14-25 1 /83)