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APPLICATION FOR PERMIT SAN JOA QUIN LOCAL HEALTH DISTRICT 3 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 # PERMIT EXPIRES l YEAR FROM DATE ISSUED (Complete in Triplicate) ribed. This cation is or install the work Application is hereby made to the San Joa�urn Local Health District for a permiNo. 1862 forconstruct well pump and the Rules and IR gulations of the San l Joaquin made,in compljance„wrth,San JoaquinGu _onryOr,�mance No, 549,f oraewage o Local lieal�h?l�isinct"'jf`ry ii�'T'3 - u, : �Y,,.".� qy MLot Size 4.01 Arrp, - PM Job Address n la o dcity � Address P Phone Owner's Name . - 11 Contractor gnn Bros. Address License No. 29(lfi l�� Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER LJ SEWER LINES DISPOSAL FL ._�} D. gF1.� PROP. LINE -- DISTANCE TO NEAREST: SEPTIC TANK __jlon' -PITS/SUMPS FOUNDATION `� ' -AGRICULTURE-WELL`- OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r� Dia. of Well Excavation Dia. of Well Casing � C1 Industrial L1 open Bottom El Manteca Specifications !`Y Gravel Pack �3 Tracy Type of Casing M Domestic/Private l oQ_!_ Type of Grout�11t`.Qn1-�e--. ❑ Public ❑ Other Cl Delta Depth of Grout Seal I I irrigation ��._Approxi.!Depth I 1 Eastern Surface Seal Installed by_ H.P. State Work Done Repair Work Done ❑ Type of Pump € Material (top 50'1 Well Destruction ❑ Well Diameter Sealing Depth Filler Material (Below 50') l TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION i I DESTRUCTION i I (Nailableo septiw thin system emitted if public sewer is Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms „- Water table depth Character of soil to a.depth,of 3 feel[:' - Capacity No. Compartments t SEPTIC TANK ❑ Type/Mfg i I Method of:Disposal f PKG. TREATM•E_NT PLT,,fl =; s Distance to nearest: Well Foundation Property Line k Total length/size LEACHING LINE ❑ No. 6 Length of lines property Line FILTER BED LlDistancerto nearest: Well Foundation � +I eSize Number SEEPAGE PITS I l Depth - Pro ert Line - .«SUMPS - - -- Ll-Distance-to nearest: �.Well _ _.FoundationT � P Y DISPOSAL PONDS ❑” 1 I hereby certify that V 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, 1 shall not 1 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring csub-contracting signature certifies the following: "I.certify that iA 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 reverse side 3_14-90 I Hennings Bros. By Title: Date: Signed X FOR DEPA drawing," USE ONLY Date Area Application Accepted by 11 3 9�] I Date Final Inspection by Date Pit or Grout Inspection by /w� ISS was g3 Additional Comments: o ! C1Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy -6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 110 !y� S qJO FEE AMOUNT DILE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO 3 I I3 rEH 13-241REV.t 1 EH 14-2e