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�.d APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELiON AVE., STOCKTON, CA 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. Job Address S F rornpr Of I innplCorral Hnllow city TRACY Lot Sae PM Owner's Name RFST RI OUS , INC. Address P 0 R(1X RR1 Phone(415 7`_r__OFi-1111 Contractor HENNINGS BROS. DRILLAddress 3.525 PELANDALE AVE_ License No. 290813 Phone -11 TYPE OF WELL/PUMP: NEW WELL XX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 10f)'4- SEWER LINES 1001+ DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE ,�, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I51r Dia. of Well Casing 11 EX Domestic/Private Q(Gravel Pack (X Tracy Type of Casing STFFI Specifications I'l Public ❑ Other ❑ Delta Depth of Grout Seal 100 t Type of Grout NEAT_MFW I I Irrigation _.Approx. Depth I I EasternsiSurface Seal Installed by HENNINGS BROS. DRILLING Repair Work Done ❑ Type of Pump ii.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet) Op Installation will serve: Residence_ Commercial_ Other C� 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 1� l� LEACHING LINE ❑ No. & Length of lines Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' I hereby certify that 1 lne 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." a The applicant must call for all required inspect ions. Complete ddrra in reverse Signed X it � Date: 1 \`3Q FOR DEPARTMENT USE ONLY 1_ Application Accepted by Date �� rea , Iv Pit or Grout Inspection by Date Final Inspection by to Additional Comments: /002— os ❑ Stk 466-6781 ❑ Lodi 369-38210 Nrlanteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2(109, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMI7'NO. INFO p A� 1777rrr e..w .�1 • E112/(REV.r/M41 t{�0 EN 1424 V "'VVV��- IIIVVV Jo V t V