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i " APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) 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 in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District._ 2—16 5'--I ej— JS Job Address Corner of Santos 'Ave. & ti._ Ave. City Ripon Lot Size PM (_1:tQ o^) C.CS D Owner's Name Diede Construction Address P.O. BOX 1007, Woodbridge Phone369-8255 Contractor Kennings Bros.-__Address 3525 Pelandale Mod. License No._22D813_Phone545-1185 TYPE OF WELL/PUMP: NEW WELL EX WELL REPLACEMENT ❑ DESTRUCTION ❑ 1JI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 460// SEWER LINES DISPOSAL FLD. 422 PRO 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 rr Dia. of Well Casing 1011 i ❑ Domestic/Private IX Gravel Pack ❑ Tracy Type of Casing sted I Specifications IX Public C1 Other ❑ Delta Depth of Grout Seal t1 Type of Grout_-._,CeCIlut_. -1 I I Irrigation —,Approx. Depth I I Eastern Surface Seal Installed by_ d 1 11 1 er Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is ^" available within 200 feet.) r_ 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- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation_ Property Line DISPOSAL PONDS ❑ 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 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 must call for all required inspections. Complete drawinn re r id . Signed x Hennings Bros. By Title. t Date: 3-9-90 F R DEP USE ONLY Application Accepted by Date Area / Pit or Grout Inspection by Date �Fin:a�lln;sp;ection Dat � pAdditional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6386r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 901 IFEE NFO MOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE J PERMIT NO. EH 14-26 + EH 13-241REV.k/xsr —70,0—D 1V--#:>2A9, 0 � VVV 66