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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :C {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. Job Address 141651,:-Palm 64;0 _ citr_Rii pon Lot Size ± PM Owner's Name Southwest Hide Co. Address P.O. Box 2083--Manteca, CA. Phone Contractor Hennings Brothers Address 3525 Pelandaie Ave License no. 290813 Phone 209 545-118 , TYPE OF WELL/PUMP: r--- NEW WELL EX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _=L±_ SEWER LINES 100'± DISPOSAL FLO.100'± PROP. LINE10D- FOUNDATiON 50'± AGRICULTURE WELL 10O'±OTHER WELL 100' + ± PITS/SUMPS 50 – INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ® Open Bottom ❑ M 1 Manteca Dia. of Well Excavation Dia. of Well Casing 6" ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PUC � ❑ Public Other L1 Delta Depth of Grout Seal ' Specifications Type of Grout Concrete 4 El 35�4pprox. Depth ❑ Eastern Surface Seal Installed by Contractor Repair Work Done ❑ Type of Pump --N/A— H.P. VA State Work Done � Well Destruction ❑ Weil Diameter Sealing Material {top 5o'I Concrete Q �v�ory Depth ., (�± Filler Material (Below 50') Sand ' TYPE OF SEPTICWORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PK& TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size Ale FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 f r 11 ed inspections. Complete drawing on reverse side. Signed _-Title: Marlager Tana Mans, Date: 5 September 1986 R R DEPARTMENT USE ONLY Application Accepted Date Area_00 —,_ Pit or Grout InspectioaydWDate Final Inspection by Date /f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO C K RECEIVED BY DATE PERMIT NO. EH 13-24 a EH 1426/REV,1/8 51 C�� S� J � p