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'i APPLICATION FOR PERMIT r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE I-SSVM (Complete in Triplicate) Application is hereby made to San Joaquin County 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 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.'/ Job Address - _ Z r�" _., —� � �� City MA- T F('A Lot Size/Acreage OWne►'sName OAKWOOD LAKE Address 874 E . WOODWARD RD. Phone 239-2060 Contractor HENNIN.GS BROS . Address .3525 PELAN DALE AVE_ License No. 29�813 Phone545-1185 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION'EX Out of Service well C1 .PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CXX "�1in4 Well ❑ DISTANCE TO NEAREST: SEPTIC TANK NONE SEWER LINES _N.0 BLE____ _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 13 Open Bottom Xi Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 11 Tracy Type of Casing_ Specifications ('1 Public 1-1 Othef n Delta Depth o1 Grout Seal Type of Grout I i Irtioation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth TEST HOLE Depth Tiller Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRIADDITION ( I DESTRUCTION I I INo 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. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of linea Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Cl 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, snd�' ! rules and regulations of the San Joaquin County Homs owner or licensed agent's signature sonifies 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." 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 reverse side. IN Signed X Data: OCT. 22 , 1992 JRjEPA MENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inape tion b Date 6 Additional Comments: Applicant - Return all copies to: San Joaquin County Public ealth Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'N ENMIREY.,ies, �� EENt4•MzaJ_..J ,,?Z �„� p (,�v•o p Ifo