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of i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZELTON AVE., STOCKTON, CA + R Telephone (203) 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 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 1B62 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 29555 E. Oran a Ave . City Esc al on Lot Size PM Owner's Name Manuel de CASTRO Address 1881 FOOTHILLS CT. Oakdale Phone 847-2126 Conhacta f rnpr frtrt Address License No- a-h-4411366Phone" A 4 7- TYPE OF WELLIPUMP: NEW WELL ❑ WELL,REPLACEMENT ❑ DESTRUCTION C7 PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER D DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2 Industrial EJ Open Bottom Cj Manteca Dia- of Well Excavation Dia. of Well Casing , ❑ Domestic?Private Ci Gravel Pack ❑ Tracy Type of Casing Specifications {� r-i Public 17 Other F l Delta Depth of Grout 'Seal Type of Grout I i Irrigation — Approx. Depth I I Eastern Surface Seal Installed by I a Repair Work Done LJ Type of Pump H.P. State Work Doric Well Destruction 0 Well Diameter Sealing Material (top 501 Depth Filler Materia! (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATIONxtXix REPAIRiADDITION I 1 DESTRUCTION I i (No septic system permitted it public. sewer is available within 200 feet.) installation will serve: Residence% Commercial— Other Number of living units: 1 Number of bedrooms_ 3 Character of soil to a depth of 3 feet: sand ,rock, Clay Water table depth + SEPTIC TANK TypelMfg P & L Concrete Capacity 12 0 o Na. Compartments 2 PKG. TREATMENT PLT.'❑ Method of Disposal 1e a C h 1 n& 5 u 91 Distance to nearest: Welt I Foundation 10 Property Line LEACHING LINE ON No- 8 Length of lines 2 @ 75Total length/size 3000 Sq .ft . jro� FILTER BED 0 Distance to nearest: Well 115 foundation 30 r Property Line 22' t SEEPAGE PITS �; Depth 2.5 Size 3 3" Number 2 SUMPS U Distance to nearest: Well 165 Foundation An Property Line 24' DISPOSAL PONDS ❑ E I hereby certify that I have prepared this application and that the work wfli 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 ust all fpr re -ed inspections. Complete drawing on reverse side. Signed XTitle: Date: EPARWENT USE ONLY I Application Accepted by . 41QAO% I, Date ,o` Area Pit or Grout Inspection by Dale _. Final Inspection h _ Date/z 01 Additional Comments: ❑ Stk 466-6781 G Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services IWI E- Hazelton Ave., P.O. Box 200k Stk., CA 95201 ° FEE AMOUNT DUE AMOUNT REMITTED ICK S AtCEIVED BY DATE PERMIT'NO. INFO . H3 �a1�>_v.t,M" 114 60 � .a 0 -koe � Co-3c�—�� ga --£3 3 "