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APPLICATION FOR PERMIT — SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON 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 3925 W. Linne Rd. City Tracy Lot Size PM Owner's Name d•d• Most Const. Address 3941 A Hol ly Dr. , Tracy Phone A3 L6g_911 Contractor Hennings Bros- Address 3525 Pelandale, Mod. License No. 290$13' Phone_J45 1185 TYPE OF WELL/PUMP: NEW WELL Dl WELL REPLACEMENT ❑ DESTRUCTION ❑ a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 120 I SEWER LINES DISPOSAL FLD.120(+ 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 Dia. of Well Casing 611 DO Domestic/Private I(1 Gravel Pack X1 Tracy Type of Casing PVC--__ Specifications 11 Public Cl Other H Delta Depth of Grout Seal 100, Type of Grout Benton 1 e. I I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by Dri I Ier Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter — Sealing Material [top 501 Depth a U Filler Material I Below 501 i k TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other r Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ -'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal b 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 IF SEEPAGE PITS l 1 Depth Size Number ire 1s i 1 IL, SUMPS L71 Distance to nearest: Well Foundation Property;Line DISPOSAL PONDS ❑ fI hereby certify that t 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 Di?;trict. 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." I r The applicant must call for all required inspections. Complete drawing on verse side. Signed x. Hennings Bras. ByT Tide: Date: 11-28-90 ///,/, -FOR ART NT USE ONLY Application Accepted by h IDate `/ Q : Area —2— 1 [� I Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ^�k+`�V ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. I l +.EH 13-24(REV.t i n 5) 4'; �© R� u r•'�f� EH 14-26 ( 'ilk i