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APPLICATION FOR PERMIT r - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 , PERMIT EXPIRES '{YEAR FROM DATE ISSUED 4 (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. I .lob Address 21909 Corral Hollow Rd. city 'Tracy Lot Size PM Owner's Name Corral Hollow Realty Address 1486 W. 11th St.., Tracy Phone 836-0890 Contractor Hennings Bros. Address 3525 Pelandale, Mod. License No. 294813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Xl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout_ I I Irrigation _..Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destructi � Well Diameter 6n Sealing Material Itop 50'i Rentonite pel IPts�lfo € ' S -rlDepth, � Filler Material (Below 50'a — RPntnnite_pellets YPE OF SEP, IC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION l I DESTRUCTION l I INo septic system permitted it public sewer is available within 200 feet.] ..: •s � �; y27i-. (��i� Installation will'seNd: -'Residence Commercial_ Other Number of living units: Number of bedrooms # pC Ht:1111t r'r1-. .K. ! .. f. v1 _ _ Character of soil'to'a depth of 3Met: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS 1 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line C2 DISPOSAL PONDS-171— - _L� ,- - _ ' 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( V 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 drawing on verse side. Signed X Hennings Bras. By Title: Date: 7-10-91 I DEP ENT USE ONLY k Application Accepted bykA�IAZI DateArea Pit or Grout Inspection by Date Final Inspection by4 Date LLL I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant - Return all copies to: Environmental Health Permit/Servicas 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE' AMOUNT REMITTED C RECEIVED BY DATE PERIIIMIT'NO. EH 14-2a +.EH 13-241REV.i/x57�//� /1; y �O n AI W lJ