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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 D �ONME 1 v\65 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE ENv1?;X14\z (Complete ip Triplicate) cribed. This application is nstall the Appkicn des at+an+s hu+eby made to the u '.Courlry Ord rSance No 549 for sewage ori1No. 1862 fo t to Cwe 1ldpumlp and the Auoles and rk 'Regulations of he San Joaquin made'+n compliance w+2h San`Joaq .r. d?: ` r a » k '. f Man a Lot Size PM i . 205.99 `S. Mal�teca Rd. x` >- city Jab Address Owner Name Sam Westste. n Address 20599 S. Manteca. Rd M Phone - Hennings Bros. Address 3525 Pelaridale Mod. License No. 29083 Phone - Contractor WELL REPLACEMENT X)( DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL D OTHER El PUMP INSTALLATION El DISPOSAL REPAIR ❑ i PROP. LINE a1SPQSAL FLD.� -� DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES � OTHER WELL PITSISUMPS FOUNDATION AGRICULTURE WELL w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Die of Well Casing t� I ❑ Open Bottom Manteca Dia. of Well Excavation u ❑ Industrial Type of Casing P 1C Specifications X(Domestic/Private (Gravel Pack ❑ Tracy t Type of Grout�e� Onite n Other C� Delta Depth of Grout Seal dri 1 le - 1 1 Public Surface Seal Installed by r _-Approx. Depth i I Eastern State Work Done — I I irrigation p e of Pump __�� H.P. r Repair Work Done ❑ Type Sealing Material (top 501 Well Destruction ❑ Well Diameter Filler Material (Below 501 Depth 9 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPA3r1 ADDITIQN l i DESTRUCTION I } alvailable+w within 200 feet.) ined 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 feet: Capacity�� No. Compartments SEPTIC TANK ❑ Type/Mfg Method,of Disposal PKG. TREATMENT PLT, 0:; Foundation Property Line I F Distance to nearest: Well LEACHING LINE ❑ No. & Length of lines Total lengthlsize IFoundation Property Line FILTER BED ❑ Distance to nearest: Well SEEPAGE PITS l } Depth Size Number Foundation Property Line - SUMPS D Distance to nearest' Well - DISPOSAL PONDS O 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 Dssue istrict work for Home owner or son n such manner as torbecome subjectolto workman's compensation l"I certify that in the aws of performance California." Contractor's which rhiri gr or sub-contracting s permit is i d l signature employ any pe certifies the person following: u certify that s the performance of the work for which this permit is issued, l shall employ persons subject to workman's carnpensa tion laws of California." The applicant must call for all required inspections. Complete drawing on arse sid Date: signed Hennin S Br o . By Title: + FOR DEPA ENT USE ONLY ! �} Date r a Area Application Accepted by �� G] Final Inspection by Date Pit or Grout Inspection by F Date -or — Additional Comments: 11 Stk 4&6-6781 D Lodi -3621 (� Manteca 823 7104 ❑ Tracy 835-6385 P.O. Box 2009, Stk., CA 95201 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., CK RECEIVED BY DATE PERMIT*NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO 4.EH 13-24(REV.1/8 5Y EH 14-26 - -