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Ili APPLICATION FOR PERMIT <br /> G� SAN JOAQUIN LOCAL HEALTH DISTRICT AYM EN'[ <br /> 1� RECEIVED <br /> { L 1601 E. HAZEL' —I ON AVE., STOCKTON, CA <br /> Telephone. 466-6781 <br /> _ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OCA 7 1887 <br /> �1Z (Complete in Triplicate) ENVIRONMENTAL HEALTh <br /> Application is Ihereby once with San Joaquin he.S nCo Joaquin <br /> Ordnance Health <br /> District <br /> for sewage or it to construct 1862 for well/dpump and he Rules and Regll the work herein d ulati SaJoaquin <br /> r1f made in comp � 2 <br /> Local Health District. <br /> 20412 S 'NAGLEE RD... - city TRACY Lot Size PM <br /> Job Address <br /> Owner's Name JEFF PHELPS Address <br /> 20412 S. NAGLEE RD'. TRACY Phone 836-1110 <br /> "Contractor HENNINGS BROS. DRILL.Address 3525 PELANDALE AVE. MO License No. 290813 Phone 545-11 85. <br /> TYPE OF WELL/PUMP: NEW WELL ❑,. WELL REPLACEMENT DESTRUCTION ❑ 4 <br /> ti PUMP INSTALLATION ❑ ' SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 0 0 } SEWER LINES 100 h DISPOSAL FLD. PROP. LINE a <br /> FOUNDATION AGRICULTURE'WELL' OTHER WELL - - "PITS/SUMPS, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ir <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ industrial PVC 1 6 O a Specifications <br /> "Domestic/Private T of Casing—PVC <br /> C�Gravel Pack X7 Tracy Y� g ��� $2ftl;Onit@ <br /> El ❑ Delta Depth of Grout Sea! — Type of Grout <br /> ❑ Public HENNINGS -BROS . DRILLING CO <br /> ❑ Irrigation 'Approx. Depth El Eastern Surface Seal Installed by <br /> Repair Work Dane ❑ Type of Pump <br /> H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> I Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nopti sy nem permitted if public sewer is <br /> avae Installation will servei Residence,, " Commercial, Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to;a de pth.of 3 feet: No. Compartments <br /> SEPTIC TANK 171 .,Type/Mfg Capacity <br /> PKG. TREATMENT PLT ❑ <br /> Method,of%Disposal <br /> Distance to nearest: Well Foundation Z 0 <br /> Property Line <br /> A <br /> ,. Total length/size <br /> f LEACHING LINE ❑ No. & Length of;lines Property Line <br /> r Foundation <br /> I FILTER SED ❑ Distance to nearest: Well <br /> Y <br /> SEEPAGE PITS C1 Depth Size Number <br /> SUMPS El ' Distance to nearest:� Well Foundation Property Line <br /> ^a r <br /> DISPOSAL PONDS L <br /> I hereby certify that! have prepared this application and that the work will be done in accordance wrthlSan Joaquin county ordinances,'state laws and <br /> rules and regulations of the San Joaquin Local Health District. <br /> 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 <br /> f employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following: certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> j tion laws of California." <br /> I The applicant must call for all required inspections. Complete drawing on 1.verse side. r <br /> Title <br /> Date: <br /> Signed <br /> FOR DEPART E T USE ONLY �0 <br /> r Date Area <br /> Application Accepted by <br /> L Pit or Grou Inspection by -/'032 — Date <br /> 3 Final lns action by Date <br /> Additional Comments: Ll00 <br /> and <br /> E3 Stk 466-6781 ❑ Lodi 3621 ❑ Manteca ,823-7104 El Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CKPERMIT N0. <br /> INFO AMOUNT DUE AMOUNT REMITTED �179jg5 <br /> +EH 19-24(REV.1/851 l �Ve ��� <br /> EH 14-28 l•r . <br />