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Fy. Y r APPLICATION F01'PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT -� 1601 E. HAMILTON AVE., STOCKTON, CA L �( Telephone {209} 466-6781 rJ 7- PERMIT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (Complete in Triplicate) 114 d DG Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described• This a plication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquinfl, i Local Health District. Job Address 1196 'Uhi'oV Ave'. ' Manteca z2� qq City Lot Si ply i Owner's Name Ernie Strauman Address 1196 Union Ave. , Manteca Phone 823- 1768 Contractor's Name Hennings Bros . License No. 290813 Phone 5 4 5—1 1 8 5 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ^�* DISTANCE TO NEAREST: SEPTIC TANK 75 F SEWER LINES _ DISPOSAL FLD. 75 ! PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS S ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom EXManteca Dia. of Well Excavation6 Dia. of Well Casing )[](Domestic/Private IX Gravel Pack ❑ Tracy Type of Casing PUB Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 5 0 1 Type of Grout B e n t o n i t e ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by d r i I 1 e r Repair Work Done ❑ Type of Pump 'H,P. State Work Done 0 0 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is {E available within 200 feet.) Installation will serve: Residence_ 'Commercial 4 Other i Number of living units: Number of bedrooms ' P Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg,;1 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 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth f Size ^� Number SUMPS ❑ Distance to nearest: Well -Foundation Property Line DISPOSAL PONDS ❑ s 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 st call for all required pections. Complete drawing on reverse si . Signed Title: Date: 8-5-84 4�FOR DEPARTMENT USE ONLY ' Application Accepted byDate _ Area y I 1 Pit or Grout Inspection by Date Final Inspection by p / r f- Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Bax 2009, Stk., CA 95201 's - FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED-BY DATE PERMIT''N0. INFO + EH 13.24(REV.10183) t . 45 �1 y Q ,7 / / p EH 1428 L+!50 0`�7 g'1 a"T vI d f