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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PER N0. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` Complete in Triplicate) 22 62 N. ,�dr IV Application is hereby made to the San Joaquin oca. Health District for a permit to construct and/or install the work herein described. This application is mad'e. 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. Job Address North R i_p on R•d .i-'jami.. North Subdivision Name0f M11ge0 , east Side Owner's Name Walter - V i s s e'r Address 22562 N • R 1 p o:n R . , 1 p o n Phone Contractor's Name Hennings B r o s . License No. Phone TYPE OF WELL/PUMP WORK: NEW,w ELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Q �R S \N PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK '! G O ' SEWER LINES DISPOSAL FLD. S a + PROP. LINE FOUNDATION f AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS17 i Industrial ❑Open Bottom Manteca Dia. of Well Excavation Domestic/Private +�]Gravel Pack ❑Tracy Dia. of Well Casing 6", PVC Public ❑Other+ ❑ Delta Type of Casing P V G fir` A irrigation th ❑ a 6� LJ 9 Approx. Eastern specifications ❑Cathodic Protection Depth of Grout Seal F-1Geophysical Type of Grout Benton l e F-1Other Surface Seal Installed by r 1 e r Repair Work Done ❑ Type of Pump H.P. State Work Done d, Well Destruction ❑ Well Diameter( Sealing Material (top 50') Depth Filler Material (Below 50') ' i ` TYPE OF SEPTIC WORK: NEW INSTALLA+ION EJ ❑REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) I Installation will serve: Residence — Commercial _ Other Number of living units: INumber of bedrooms Lot size Character of soil to a depth of,3 feet: Water table depth r Compartments 1 SEPTIC TANK E] No.Type/Mfg Capacity P 1 PKG. TREATMENT PLT. (] Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. h Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE, PITS ❑ Depth Size Number ii SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l -hereby certify that 1 have prepared this application and that the work will be.done in accordance with San Joaquin county ordinances, state laws, and rules end regulations of the Sam Joaquin Local Health,District. : Home owner or licensed agent's signature certifies the following: "I certify.that'An -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 compensation laws of 'California." t 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 w kman's compensation laws of California." The applicant must call for all requir�ioqs. m ete drawing on reverse side. 4-23- s;gned xyennin s Bros . 4byT Date:NT E ONLY // Application Accepted by Z_VJ e�-26 ❑ Stk 466 6781 Additional Comments: ❑ Lodi 369-3621 C Pit or'Grout Inspection by Date 'Manteca B23-7104 Final Inspection by 11. Date ❑ Tracy 835-6385 Applicant - Return all cop �o., EnvironmEnta l Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2o09, Stk., CA 95201 i FEE ,` BASE AMOUNT :DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. ' INFO f3 EH 13-24 REV. 10/82 �� q ll 4u 10/82 500 �� 14-26 { Irifj�vl`f�Yfi�+ �0 57A0V- w- /�UL•► �y G�'ec� "