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APPLICATION FOR PERMIT AY 1 V AT y r SAN JOAQUIN LOCAL HEALTH DISTRICT p so 1601 E. HAZELTON AVE., STOCKTON, CA REG Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) EA is i�IV1RONMENT��A��LH�� , Application is hereby made to the San Joaquin Local Health District fpr a permit to construct and/or install the work here�n des �ppit uft is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wellipump and the Rules and Regula ns of a San Joaquin Local Health District. -.. `� _ '. ' Job Address 22651 S. TINNIN RD . city MANTECA Lot Size .3 46u1' PM owner's Name TOM HEDEGARD Address 1025 JANET LN . MANTECA Phone 823- 1952 ContractorHENNINGS BRAS. DRILL. Address 3525 PELANDALE AVE. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ c�e PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ _ PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL— PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u ElIndustrial 13Open Bottom X7XManteca Dia. of Well Excavation 12" - Dia. of Well Casing (Domestic/Private [1(Gravel Pack ❑ Tracy Type of Casing PVC 160 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout SealUU Ty of Grou ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by RE N N I NGS BR O S Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth 7 Filler Material (Below 501 6"'6 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 171 DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) + Installation will serve: Residence— Commercial_ Other - er of living units: Number of bedrooms _ Character o e th of 3 feet: Water table depth SEPTIC TANK ❑ Type Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foun Property Line LEACHING LINE ❑ No. & Length of lines. Total length/size— FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number - SUMPS ❑ 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, 1 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 subjectto workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete dra g `'/reverse evee side. " Signed Title Date: F DEPART ENT USE ONLY Application Accepted by Date-/10 Area Pit or®r,.tpection by - Date_!y ! Final Inspection bye Date i'r-�7��7 t Additional Comments: �- ❑ Stk 466-6781 11 Lodi 369-3621 v❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Leith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT N0. e INFO + E14 13-24 IREV,I/e 5) / / ��,�J H,14426 l0 LLLsss"' -