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APPLICATION FOR PERMIT pr g� 1�VO SAN JOAQUIN LOCAL HEALTH DISTRICT J 1 1601 E. HAZEL T ON AVE., STOCKTON, CA ��II 6 Telephone (209) 466-6781 [./1// 2 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f p£RoyT � 8 (Complete in Triplicate) 'fR�j�I�',y 1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein de cr ted (oration 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�'t}�7'e San Joaquin Local Health --District. Z0 —i — 6 d Z`Z n.(..®n' Rd.-Imi le north of.La�thro Rd. each,#, side Lot Size PM ,,Job Address Owner's Name Address Phone 2-58-26.15 1 ' Contractor Hennings Bros. Address 3525 Pelandale MOd. License No. 290813 Phone 545-1185 � TYPE-OF WELL/PUMP: NEW WELL CX WELL REPLACEMENT ❑ DESTRUCTION D -� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ yi OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK nOna SEWER LINES DISPOSAL FLD. PROP. LINE N FOUNDATION AGRICULTURE WELL OTHER WELL ' PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation 26 Dia. of Well Casing 16" ❑ Domestic/Private CR Gravel Pack ❑ Tracy Type of Casing Stoel Specifications 17 Public €=1 Other ❑ Delta Depth of Grout Seal Type of Grout —0— I X Irrigation _____.Approx, Depth I ],Eastern Surface Seal Installed by _ Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction El Well Diameter Sealing Material [top 501 Depth Filler Material IBelow 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION C1 REPAIR/ADDITION I 1 DESTRUCTION I I lNo 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 M� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line M, LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line O SEEPAGE PITS l I Depth Size Number SUMPS ❑ 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: 1 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."Contractors 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 Comlate di Ing on reverse wide. Signed XHenn i nig Rrnc- R� 1/l P� 1 t� i Date: __6-1-8 FOR ARTMENT USE ONLY r; Application Accepted by Date � ^''Area 1 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy '835-6385 Applicant - R rn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. f.EH13241REV.iinsi s� [, 60 EH t4-28 11