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APPLICATION .FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.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 pgrmit 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. > Job Address J 25785 E. Deck Rd. City EScalon Lot Size 2 ores PM F Owner's Name Louie Cabrera Address J 25.785 E. Deck Rd..-, Escal-on Phone 83 -3186 Contractor HenningS Bros. Address 3525 Pelandale, ModeSIOLicense No._290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100'+ SEWER LINES DISPOSAL FLD. 100' PROP. LINE F FOUNDATION AGRICULTURE WELL OTHER WELL�QL PITS/SUMPS INTENDED USE TYPVOF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIONS" ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12" Dia. of Well Casing 6tt X Domestic/Private .)] Gravel Pack ❑ Tracy Type of Casing PVC Specifications r l`l Public ❑ Other Ll Delta Depth of Grout Seal >Id0 Type of Grout Rpntnn i tp �- I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by driller- Repair riIlerRepair Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 50')" TYPE OF SEPTIC WORK: NEW INSTALLATION i-1 REPAIR/ADDITION i I DESTRUCTION i I Wo septic system permitted if public sewer is available within 200 feet.) a Installation will serve:!, Residence_G Commercial_ Other Number of living units: Number of bedrooms r� .,.� Character of soil to a depth•of 3 feet: Wat�r make t.e� ' I e SEPTIC TANK ❑ Type/Mfg Capacity No Coinptattments r PKG. TREATMENT PLT. ❑ G1 f c Method;of Disposal Distance to nearest: Well foundation Property-Line MAR i LEACHING LINE .❑ No. & Length of,lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property lCi,<1�'.'){��%i'yi IE:N'DL ES `I_iY RNI SEEPAGE PITS f I Depth Size _ Number SUMPS Ll 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: "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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawingverse side. i Signed x Hennings Bras. By Title: V; Date. 3-23-89 FO EPA USE ONLY Application Accepted by Date :3—o 7�� / Area (357 Pit or Grout InspectioFinal Inspection by Date C. i Additional Comments: �cr✓K-e 711 �� _5?4Z – 741 �.,,,� •,� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE r INFO AMOUNT DUE AMOUNTREMITTED RECEIVED BY DATE PERMIT' 0. +.EH 13-21(REV.1 w 5) ��a t EH 11-2e 1 F ,