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AfiI. - APPLICATION p swl SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 p � 1 1988 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) tsVIRONMEN�AI'HEATH p SIT SMVICE5 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein scribed. 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 GALLECO HOMES CityFRENGD CAMP Lot'Size PM Owner's Name SAM GALLEGO Address 9635 S. WOLFE ROAD, FRENCH CAMPPhone 209 982-5177 Contractor EE Address NIA License No. Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION- I, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE �-' — - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP-S-. .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other - F Delta Depth of Grout Sea] Type of Grout _ I 1 Irrigation _.Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction IN Well Diameter 6 inches Sealing Material )top 501 Sand and cement 75 feet Sand and cement I` Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION { I DESTRUCTION I } (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. ❑ w Method of Disposal Distance to nearest: Well Foundation Property Line j. LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS L� Distance to nearest: Well Foundation Property Line f 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." 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 musfor ail uired inspections. Complete drawing an reverse side. Signed X Title: OWNER Date: 12/09/88 FOR DEPARTMENT USE ONLY l Application Accepted by Date[' f Area Pit or Grout Inspection by Date Final Inspection by -� Date Additional Comments: ' r?,r e SC"2:4- i r t,^G 4��-(l .r c� ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca a23-71W ❑ Tracy 835-685 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2409, Stk., CA 95201 FEE7 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY / DATE pPERM)T'NO. ♦.EH 13-24 1 REV.1/9 5) ! 2Cr� tJ U� � M14. EH 14-28 _ / I