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�7y � APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE„ STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ' (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. j Job Address City TRACY Lot Size PM Owner's Name W.D.O. CORP . Address P BOX 134 TRACY Phone —8-3-5-- Contractor HENNINGS BRAS. DRILLAddress 2 3525 PELANDALE AVE. License No. 29081 _Phone_545-1185 TYPE OF WELL/PUMP: NEW WELL XJ WELL REPLACEMENT ❑ DESTRUCTION ��// ! PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER * y UA4 k Oil DISTANCE TO NEAREST: SEPTIC TANK 1_00t+ SEWER LINES 100 ' 4: DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ 14.. Dia. of Well Casing 8n Jf;]1(Domestic/Private IX Gravel Pack (Tracy Type of Casing PVC Specifications 1-1 Public f-7 Other ❑ Delta Depth of Grout Seal 100 , Type of GroutBM0N1JF _. I I Irrigation _Approx. Depth I I Eastern Surface Seal installed byH F N N I N G S B R O S_ DRILLING 11._ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I 1 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING UNE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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, 1 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 applic'a'nt must call for all required inspections. Complete drawing on reverse side. SignedX��(�f1�CL 1 S1ti�1` p�1 ` �L1 [1vL TitlVRTMENT a Date: _. 1 ► t—`7 ;' FOR DE USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by ate D 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 1 CK RECEIVED BY DATE PERMITNO. INFO CASH ..EH 13-24(REV.r/n a) 7 EH 14-26