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_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAY +e7° 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 U f 19,91 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED SAN JOAQtjlN COQ r� (Complete in Triplicate) ENV q0 PUBLIC VIAL HFi Sf?V" '-S MENTAL dA�� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install,the work herein describedhYsTa' lfgn;�s 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 3601 Undine Rd. City Stockton Lot Size 135 acres PM Owner's Name .v In �erri & Son Address _2795 W. ))❑dine Rd. , Stockton Phone 465-8641 Contractor Hennings Bros. Address 3525 PeiandaLe, Mod./ License No. 290813 Phone_545-1185 TYPE OF WI=LL/PUMP: NEW WELL CJ WELL REPLACEMENT L DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1451 SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL--13–Y— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6 u XX Domestic/Private XX Gravel Pack ❑ Tracy Type of Casing PVC Specifications f'1 Public D Other CI Delta Depth of Grout Seal 20' Type of Grout Bentonite _ I I Irrigation -Approx. Depth I 1 Eastern Surface Seal Installed by rl l ler ( j Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction El Well Diameter Sealing Material [top 501 ,�rnt IE.�P De thrFiller Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 1 l DESTRUCTION €1 (No septic systemtpermietedlif public sewer is available within 200 feet.) i lvir r Installation will serve:) Residence l •)Commercial_ Other ri I ) 6 854 Number of living units: Number of bedrooms Character of-sad to a'depth of 3 feet: Water table depth 8 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments EKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest'. Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 6" XX SEEPAGE PITS i I Depth Size _ Number ' ,.i tan I te SUMPS Cl 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 subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on r"se se side. Signed X ' Henn ing�L Br_os.._- ...By Title: Yl. Date: 7-11-91 F R DEPARTM NT USE ONLY Application Accepted by J Date XY / Area Pit or Grout Inspection by C✓� Date / Final Inspection by Date 7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-744 ❑ Tracy 835-6385 `Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2005, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. r.EH 53-24 IAEV.I/1i 5S�/� 3'/ / "T/S-- f EH 14-24 ��- LJ ( ,( I