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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT., I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r I 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 incompliance with San.J_oaquin.County Ordinance,No. 54.9 forsewage or No. 1862 for well/pump and the Rules`and Regulations of the San Joaquin Local Health District. ; ! r Escalon-Bellota Hwy north side Job Address-, 23975- E. Mi 1t�n -Rd.� '1 1:mi. wesi of city Lot Size acres PM Owner's Name Jerre & Kathryn Endfin eMdrImss 10227 E, Hwy...-26, Stockton Phone 931-1844 I. ContractorRennin S RrOS. Address 3525 Pel nd License No. 2_QB13 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPtiC TANK none SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'INTENDED USE TYPE OF WELL PROBLEM AREA —CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I� U Domestic/Private U Gravel Pack ❑ Tracy Type of Casing Py l Specifications ; ('1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Bent lie__, Irrigation _.-Approx. Depth i I Eastern Surface Seal Installed by— driller )L} Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') M Depth..—- Filler Material I Below 50') Ap -- TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted.if,public sewer is available within 200 feet.) Installation Wilk server, Residence_ iCommercial_ Other 44l . . Number of living units: Number of bedrooms 1 Character of s d-to a depth of 3 feet. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' I LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line P i' SEEPAGE PITS I 1 Depth Size Number SYMPS U Distance to nearest: Well Foundation Property Line —DISPOSAL PONDS 0 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: '9 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." r A i The applicant must call for all required inspections. Complete drawing I Signed X._ Hennings Rros_ Title: _0(m n oe rse 4_t?P_ Date: 4-24-91 � OR DEPAR ENT USE ONLY Application Accepted by Date / Area Pit or Grout Inspection by ,5' h&1� Date !0 Final Inspection by Date (f J Additional Comments: ,,.Cf, / z V / Z 1�j 7U, OrStk 466-6781 Cl Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Y FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 6Y DATE PERMIT'NO. AIAqoV . /JCASH ♦.EH 13-241REV.1/is5i AI Vr fff/� s" 6 � EH 14-26