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<br /> APPLICATION FOR PERMIT
<br /> SAA: JOAQUIN LOCAL HEALTH DISTRICT
<br /> 1601 E. HAZELTON AVE., STOCKTON, CA xk
<br /> Telephone (209( 486-x',781
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
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<br /> (Complete in Triplicate)
<br /> 'i., F;ti,♦ ApplicaGnn iq hereby made to rhe San Joaquin Local Heahh Oistricl for a permit to construct and/or install the work herein dascrihM.This npplivalron'is
<br /> made in compiianw with San Joaquin County Ordinance No.579 for sewage or Nu.1862 fur well/pomp and the Rules and Raguiatiuns at the Ean Joaquin , s%
<br /> ' Loral Health District.
<br /> Wit-i....��:, - `7 . . . $,. '•�,-,t;:.�
<br /> ,G Ss l Job Address . 3501 W. UNDINE RD. C;, STOCKTON "
<br /> .t, .— y_r.. Lot Siva__1
<br /> _ PM
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<br /> LLOYD PHELPSi 3541 WU1�DINE RD. Phono 462-59944 L ' ;
<br /> s,, - r Owner s Names _-___ Redress a r
<br /> P � � f h3 1 , icnt:actor_HENNINGS BROS�„_,__•Aodress j _25—PIL MD AL-E—AIL.-License.No.—. _01 Phone.5A5-; 6:
<br /> l TYK OF,WELL/PUMP: NEW WELL LI WELL REPLACEMENT iD OESTRUCTIONX_x 'M
<br /> PUMP INSTALLATION L:. SYSTEM REPAIR [T OTHER ❑ § '
<br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _ DISPOSAL FLO, PROP.LINE }t
<br /> FOUNDATION _ __ AGRICULTURE WELL _OTHER WELL PITSISUMPSy '
<br /> �ar4AL` 2f” v INTENDED USE
<br /> TYPE OF WELL PRJRLEM AREA CONSTRUCTION $PEClFICATtOfJS
<br /> t. _ c:
<br /> t +" .❑ Industrial Cl Open Bottoin Cl Manteca Dia.of Wet;Excavation Dia.of Well Casing �,rt '.��
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<br /> ry `� e r,,3 ?fix I i
<br /> 0 Aomesticf Private C7 Gravel Pack C1 Tracy Type of Casinp__ ,Specifications G:;'•
<br /> Al" ; �a F'I Public I:1 Other 1-1DeliaDepth of Grout Seal Type o1 Grout r c
<br /> 8, I I Irri,fdrion _Appros. Depth I I EL, cern Surface Sea!Installed by
<br /> Repmr Work Done is Type of Pump H.P. _ State Work Donn
<br /> Well Destruction s Cx 'VVeq biarfeter t Sealing Malarial Imp,4)'I BEN.7.,O.N.II�PFj I FTS
<br /> td' /• �r s t' i• � ,:. r,C..:a r .rt Depth------ Q___- Filler Material BE,N_T_L1N ITE"P El I EIS
<br /> ;` TYPE OF SEPCIC WORK: -NEW 1146TAL'_ATION I I -tiEPAIRIA:)DIrION I I bESTAUCT:ON I I tNa septic system permitted if public sewer rs i
<br /> z 1`rr , ' _ .r < available within 100 Teer.F At
<br /> > �` 4l ' r i
<br /> Installation w 11 servo: ResWerce_ Commercial_ Other
<br /> rs�yx rk } 7 , Numberof living units: Number of bedrooms r g� f,
<br /> -:Character of soil Ina depth of J feet: Walter table depth
<br /> 3
<br /> tiSEPTIC TANK L]` Type/Mfg •_._, Capacity _ ._No.Compartments t` `
<br /> PKG.TREATMENT PL-: C}'. Method of,risposaf
<br /> r• '. „�l.^�,' f PR tis; --y, Y, vy P. , _ ",N, y :. f �Yi
<br /> Distance to nearest: 1Ne11 Foundation P:operty
<br /> -
<br /> ,�x���yy�•`�' ��•.��� - `t LEACHING LINE. ❑_ No.f1 Length of linos � _ � _ Total lengthlsite "' " w; r F - f •
<br /> Cl ' Distance to nearest: Well Foundation Property Line" "'x" x9'"';{ - `t' W
<br /> PITS � I I .Dapth'--^—_Site _ _"..-. _ Number,
<br /> L-I ;Distance in nearest: Well Foundation Property L;
<br /> no
<br /> 1 DISPOSAL PONOS�- C7 - � .. -� k-tom ��,,� 29
<br /> feenify that I have prepared this application and that the work wilt be done in accordance with Sart Joaquin county ordinances,stale laws and er 3
<br /> rules and regulations of the San Joaquin Local Health Doluict.
<br /> 'fid Home uwner or licensed agent's signature ce.rides the following:"I certify that in rhe performance of the work for wts`ch this permit h issued;I s. 0 nor,, !
<br /> t1R r y q 7 a� .,;semnby any person in such manner as to become subiaut[o warkm]n's compensation laws of California."Contractor's Irir€rg or subcontracting signet ist St
<br /> :.� tµ- .ds' +•t, �certifies the following:"I cenify that in the performance of the work for which This permit is issued,I shall empFoy persons vubwct to workmen's compensa.S '
<br /> r.�°4� rlion lawa of California... I a
<br /> A 'L{, ^`,T�r-;(qL * ' C� t r"The epp cant must call int oil reinihad inspections.iomplate drawing reveres side. `�;r.HJ,�'• ^ •�
<br /> .'TJ * .,ltd S'ur.r=te .- (} !r
<br /> x w j 3 s' nedX ENNTNG "
<br /> ��.R 4 Stela R T 1 I 1 N C;'��L Title: �� Date.+� 19 91 . .
<br /> fin"�7�`?T�ii�} t 1 t r` x, ; a."."., •. t
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<br /> FOR DEPART NT USE ONLY h
<br /> > t,�',�•tw ''s ,�,��t S 'f - ',.r V�1nf lig +t 'r-ke .
<br /> '„ � 1•*„ a"'� .; •� s A1,plicauon Acceptea by.L11/�,stiyy�- _ •� Data
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<br /> P�[or Grout Inspection by Date Final inspection by �/" •� Date ,n '
<br /> "Additional Comments: ^ i
<br /> ❑Stk: 466.8781 ❑ Lodi .369-362.1 ❑Manteca R23-7t04 Tracy 835 G385
<br /> y},, ,a3`yyr� p .w _Applicant Return all copies to: Environmamal Health Permit/Services 1603 E. Harahan Ave., P.O.Box 2003,51k„CA 95201
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