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APPLICATION FOR PERMIT U SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA lr Telephone; (209) 466-6781 PERMIT EXPIRES 9 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 25075 E. Clough Rd. City Escalon Lot Size PM Owner's Name Address 20558 'M�Hpenry,_Esralon Phone Contractor Henninas Bros. Address 3525 Pelandale, Mod--License No.__29D813—Phone _545-1 185 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:,SEPTIC TANK 80, SEWER LINES DISPOSAL FLD.80 t+ PROP. LINE v - -- FOl7NDATION_ "AGRICULTURE WELL OTHER WELL Oat PITS/SUMPS{_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ 12'2'- Dia. of Well Casing IX Domestic/'Private IV Gravel Pack © Tracy Type of Casing PVC Specifications M Public 11 Other Ll Delta Depth of Grout Seal 110t Type of Grout ugh a _. I I Irrigation 49zApprox. Depth I ! Eastern Surface Seal Installed by d r i I I e r - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50'i �t Depth Filler Material (Below 50') vi TYPE OF SEPTIC WORK: NEW INSTALLATION l"I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is " available within 200 feet.i Installation will serve: "Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: , Water table depot SEPTIC TANK Cl Type/Mfg Capacity No. Compartments ,R 4 I` PKG. TREATMENT,PLT.,D ,- Method,of Drsosa r a :r o nc s Ditae tnearest: Well Foundation Property Line -_ � LEACHING LINE ❑ No. & Length of-lines Total length/size-, FILTER BED ❑ Distance to nearest: Well Foundation Property Line ri SEEPAGE PITS l I Depth Size Number -SUMPS-•-. _-.y„� �LI-...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 Di3trict. 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 of 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." I The applicant must call for all required inspections. Complete drawiN_!_ A reverse side. ros.Signed XTitl � Hennings B ,�,4_e. '�_ _ Date: 5-31-89 _ _ - F DEPARTMENT USE ONLY Application Accepted by Data Area Pito Grout Inspection b Dat inal Inspection by ate Additional Comments: O 3 /0/- 02- 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ M eco 823-7104 ❑ TrAy 835-6385 �eu��.S7`�f C,-.w c4_le cl( ) Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f PEE AMOUNT DUE AMOUNT REMITTED C7K RECEIVED BY DATE PERMIT-IVO. INFO +.EH13-24(REV.f/xE7 /`�O -C)o ��-7 (�dy P -�• �`� �. EH 14-28 // CY