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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete iri 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. y # 9R010 .Innniiin rt Tram . c,_ ann Job Address AMOUNT DUE Bill 5 - Middleton Address 2304.0 . Joa Ll i n Ct.. Tracy Phone 835-3617 Owner's Name DATE Contractor Henning$ Host Address 3525 Pelandale, Mod. _`License No. 290813 Phone_ 545-1185 Contractor TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT( DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:, SEPTIC TANK 1201 SEWER.LINES DISPOSAL FLD. 120' -PROP. LINE FOUNDATION- AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom [I Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/ Private (Gravel Pack Xi Tracy Type of Casing PVC Specifications [ I Public ❑ Other ❑ Delta Depth of Grout Seal 100' Type of Grout 3211'tonite_. I I Irrigation - - —.Approx. Depth I I Eastern Surface Seal Installed by driller _ Repair Work Done ❑ Type of Pump H. P. State Work Done Well Destruction ❑ Well Diameter. Sealing Material Itop 50'1 Depth # Filler Material 18elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ,9 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 Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ") W Q 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 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 no 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." I The applicant must call for all required inspections. Complete drawing Vnver�-'�`Signed X HenningS Bros. By Title: l/l �.Q '(�Q�j Date FORTMENT USE ONLY I Application Accepted by t Date _ �! '� r_46 Area Pit or Grout Inspection by — Date J� L Final inspection by Date f Ade itinnal Cnmments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca. 823-7104 ❑ Tracy 835-6385 Applicant - Return.all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .. EH 13-24 )REV. i i e 5) EH 14-25 /1 FEE INFO AMOUNT DUE AMOUNT REMITTED 9H RECEIVED BY DATE PERMIT NO. I