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APPLICATION FOR PERMIT * ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Er1Z' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1PxTejVSO (Complete in Triplicate) R Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereir�Fgrio, -0plication is made incompliancewith San Joaquin.County Ordinance.No 549 for Sewage or No. 1862 for well/pump and the Rules and f d1tions of the S� pL*An Local Health Distrct .— ,, CY+ v,RONM+<NSAv��.5 Job Address.," '12260 W. V city Trary Lot Size PM Owner's Name Steven Ormonde Address P_0_ Rnx 1000_ Tracy Phone 225 J10AQ Contractor Henn 1 ngS Bros, Address X525 P(=I anria 1 PP MO, T License No.�QQ$l_3—Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100, SEWER LINES DISPOSAL FLD. 100' PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.Dia. of Well Casing 611 X Domestic/Private UGravel Pack )C) Tracy Type of Casing Pyr: Specifications r'1 Public FI Other ❑ Delta Depth of Grout Seal 1001 T Type of Grout_.BeRtDaite_._. lerReI Irrigation _.Approx. Depth ( I Eastern Surface Seal Installed by driller- Repair pair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION l I DESTRUCTION { 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: Welk Foundation Property Line SEEPAGE PITS I Depth Size Number SUMPS Ll 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 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."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 pn ever a side. Signed X Hennings Bros. B Title: , g y �/+-�-f�c.G�ef_ Date: 9 Q-.26—f3�3 FO ART SE ONLY r �i Application Accepted by Date Pit or Grout Inspection by Date Final Inspgction by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH a.EH 13-24(REV.I/H5) EH 14-28