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z _ I APPLICATION FOR PERMIT /^ �f✓ 9 SAN JOAQUIN LOCAL HEALTH DISTRICT }� U/ 1601 E. HAZELTON AVE., ST.00KTON, CA / b Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is haieby 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 wall/pu p and the Rules and Regulations of t e San Joaquin Local Health District. r '9.Cas' G Bell H� ' Job Address N.W. corner of Milton Rd. & Escalon- city Lot Size PM e Owner's Name Edward Rainey Address 76 Palm Dr., Union City Phona415-489-2275 Contractor Hennings Bros. Address3525 Pel'andale, Mod. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: I NEW WELL n WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SyfSTEM REPAIR ❑ OTHER ❑ --_ DISTANCE TO NEAREST: SEPTIC TANK none SEWER LINES, _ DISPOSAL FLD. PROP. LINE �L�• _ -_ OUO --.t,o,,,., :.J FOUNDATION AGRICULTURE WELL-~'OT E WELL PIT /SUMPS_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 811. XXDomeslic/Private XX GrIvel Pack ❑.Tracy Type of Casing PVC Specifications I"1 Public ❑ Othersyrl DI a Depth of Grout Seal /J�" Type of Grout Bentonite _ l _ I I Irrigation �3�F Ab'pi"a'7F.'6gp�ha�l I Eastern Surface Seal Installed by driller _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 N Deptf - Filler Material!Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is 1 available within 200 feet.) Installation will serve:I Residence_ Commercial_ Other - Number of living units: Number of bedrooms Character of soil to a depth of 3'fetet: Water table depth o SEPTIC TANK ❑ TyIpIe/Mfg Capacity No. Compartments PKG.TREATMENT PLT.❑ @ Method of Disposal Distance to nearest: Well Foundation Property Line l I LEACHING LINE ❑ Nd. & Length of lines - Total length/Size- FILTER BED ❑ Distance to rtearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number ri - .• r r. ,_,-SUMP%_ ❑ Distance to nearest:,--Well oun anon, � 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 D3trict. \ 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 I 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- I tion laws of California." The applicant must call for all required inspections. Complete drawitne!". sid Signed x Hennings Bros. BY Tit Dale: 7-25=90. . \ ORDNT USE ONLY /p Application Accepted by Date AreaPito Grout nspection b Date Final Inspection by Dale /� �✓ / / 9 `,C� Additional Comments: O"t--jOAl _ C �� •--�J r/�f� r /✓4 af�' -/ `4 ` �i ❑ Stk 466-6781 ❑ Lodi 8369-3621 ❑ Manteca 823-7104 ❑ Tracy - 5 f�/,./?d ✓✓- y Applicant- Return all copies to:Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Slit. CA 95201 r/-/3 H Qn4✓y II (C.G FEE gMOUNT OUE AMOUNT REMITTED RECEIVED eY DATE PERMI7 NO. INFO ..EH IJ.]4IREV.,in51 4 G / O o�f to , EH 103a -1 "11