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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ry 1601 E. HAZE:T ON AVE;, STOCKTON, CA Telephone (209) 466-6781 PAYMENT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RECEIVED (Complete in Triplicate) +/� 77 l 1 ;}} Application is hereby;rtiadeAolthe San;Joaquin;Local Health District for a,permit to construct and/or install the work herein d sCrit d? `ts7application is made in compkiance With San Joaqu+fi founty Ordinance No 549-tor sewage'or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin stnct x 2 F ; Jx "F, , k� ,s a«, s x �• ENVIR�NMLocal Healh Dr ENTAL HEA 101 LTF( PERMIT/SERVIC Job Address 5496 w. Ri "t Rd. ; , City Maf11:e_f'a__- Lot Size owner's Name Dutra Fams. Address 5496 K. Ripon....Rd_i_,_Manteca Phone82*1-4836 Contractor HenningS. Bros. Address 3525 Pelandale, Mod.- License No.290893 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100-11 SEWER LINES. DISPOSAL FLD:_10Q'__ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 100' PITS/SUMPS INTENDED USE TYPE OF WELL -PROBLEM-AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial °Dairy ❑ Open Bottom fl Manteca Dia. of Well Excavation 20 Dia. of Well Casing " ,�/ X] Domestic/Private EX Gravel Pack ❑ Tracy Type of Casing PUO Specifications FI Public Cl Other ❑ Delta Depth of Grout Seal ISO, Type of Grout Bentonite t l Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by - - _ •A Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION l 1 DESTRUCTION I 1 {No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other 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. 0 . 11 _ Method of Disposal Distance to nearest:. Well FoundationProperty Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number d SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application-and tharthe work will be'done'in-acitce with Sari Joaquin'6_66nty 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 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,1 shall employ persons subject to workman's compensa- tion laws of California," The applicant must call for all required inspections. Complete drawingItill erse I . SignedX Hennir� Rrnc RyTitle: 1 Date: 1-9–r�9•FOR DEPARTMENT USE ONLY Application Accepted by Date Area O Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: i ❑ Stk 466-678t ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE )NFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY J DATEt/. lPPEyRMIT'NO./! ) *.EH 13-24 1REV. /n 51 O EH 14-26