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P APPLICATION FOR PE'W.IT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 compliancewithry San JPaquin Co4,9ty Ordinance No 549,for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health`E1is4rict t ' ¢r6 r °•' r! i�2a " z t i i, h�_ Job Address 5833 ';.:Veritas Rd: t t �,..{ '; city Manteca Lot Size 255'x255' PM Owner's Name Richard Luder Address 23079 S. Manteca, Manteca Phone 823-7220 Contractor Hennings Bros. Address 3525 Pelandale, Mod. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL XX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100' SEWER LINES DISPOSAL FLO. 120 PROP. LINE _FOUNDATION _AGRICULTURE WELL OTHER WELL PITS/SUMPS— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing 611 9-] Domestic/Private JGravel Pack XX Tracy Type of Casing PVC Specifications ('-I Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout Ben n 1 e__-, I I Irrigation —..Approx. Depth I I Eastern Surface Seal Installed by driller Repair Work Done 13 Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth It$ Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is r i available within 200 feet.i installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 1 W I 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 a! LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 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 Dflarict. 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 t 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 o verse side Signed HenninclS Bros $ _ Title: Date: 5-16—go FO DEPA N USE ONLY Application Accepted by Date �~ � Area Pit or Grout Inspection by Date Final Inspection by Date �L0 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO. +.EH 13-24 IREV.r i 4 51 �-^�'EH 14-28 /v �.S�st17/ t. �t