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APPLICATION FOR PERMIT 4:))C1 In SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ptc vet) Telephone 1209) 466-6781 U&Ip PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DC {Complete in Triplicate} RQnft O 198A f Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worl� 4V. i application is made in compliance witK San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules � 1 Joaquin Local,Health District. z Job Address Hwy 205 7 Y--6-cAj City Manteca Lot Size PM Owner's Name Brown Sand Inc. Address 874 E. Woodward, Manteca Phone Contractor Hennings Bros. Address 3525 Pe1at1da e,.M0d„_License No. 290893 Phone_545-1 IRS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER A Test hole DISTANCE TO NEAREST: SEPTIC TANK none 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 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation -11_Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done— r Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l ) DESTRUCTION I I (No 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 LEACHING LINE ❑ 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__'C�- 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."Contractors 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 of�`'77ide,Signed X Title: _.7rC.t e_Cl,[� Date: FOR DEPARTMENT USE ONLY r Application Accepted by Date Area Pit or Grout Inspection by ate Final Inspection by Date Additional Comments: _ j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMODUNT DUE'e AMOUNT REMITTED �rC�ASH RECEIVED BY 2 DATE PERMIT'NO. + EH EH 11-24(REV.1195) -p6 ~� rte- M�� n '. S�-3338 ��