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�;. APPLICATION FOR PERMIT USAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 -'j-1 I('it j, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RECEIVE® (Complete in Triplicate) AUG. , 'f Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described 9i9 n application is made;n compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the R ee ulations of the San Joaquin Local Health District. I ® Job Address 6074 W. Lingle Rd: City Tracy Lot Size 2731 x240 t -_rPM Owner's Name Ormonde Development Address P.O, BOX 1'009, Tracy Phone 835-7990 Contractor Hennings Bros. Address 3525 Pelandale, Mod. License No. 290813 Phone—S45-1185 TYPE hone_ — TYPE OF WELL/PUMP: NEW WELL IX WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK 100, SEWER LINES DISPOSAL FLD. 100' PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDEDUSE`v' "TYPE OF—W.ELU�PROBLE_l AREA—CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation 1211 Dia. of Well Casing 6 u IX Domestic/Private )Q Gravel Pack Xl Tracy Type of Casing PVC Specifications FI Public 0 Other 0 Delta Depth of Grout Seal 100, Type of Grout Benton ite I I Irrigation __-_Approx. Depth I I Eastern Surface Seal Installed by driller Repair Work Done 0 Type of Pump H.P, State Work Done Well Destruction 0 Well Diameter Sealing Material Itop 501 Depth Filler Material ieelow 501 E7 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION i I DESTRUCTION 1 1 (No septic system permitted it public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial— Other T 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 LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS LZ Distance to nearest: Well Foundation Property Line = DISPOSAL PONDS- -❑ i 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, 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 mploy persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing raver a si l Hennings Bros. By 8-1-90 Signed X Title: Date: FOR DEPA NT USE ONLY Application Accepted by Date Area :2 & Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: CLQ rr3 0• E7 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE INFO AMOUNT DUE A 0UNT REMITTED CKSHRECEIVED BY DATE PERMITNO. ♦ EH 13-24(REV.tin 5) 003]& IIF EH 14-26