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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT`Y 1601 E. HAZEL T ON AVE., STOCKTON, CA 'lea Telephone 12091 466-6781 PERMIT EXPIRES'1 YEAR FROM DATE ISSUED = MAR 1 �7 lComplete in Triplicate) ENVIR OMENT AppGcatior). hereby made to the San Joaquin Local Health District for a permit to construct and/or install the woik h!!A*f rj��on is made in Ord0liance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for+tiell/pump and the Rules and p�egul Joaquin Local Health District: . r. IV Job Address 2,1335 RIVER R D City E S C A L 0 N` t Lot Size PM owner's Name NICK BELLINO- Address 21335 'RIVER RD.- ESCALON phone 599--2995 contractorHENNINGS BROS. DRILL-Address 3525 PELANDALE AVE. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL IX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ r F DISTANCE TO'NEAREST: SEPTIC TANK 250 1 •h SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 101° ❑ Domestic/Private EX Gravel Pack ❑ Tracy Type of Casing PVC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 11 Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other .i 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line (LEACHING LINE ❑ No. & Length of lines Total length/size 'TILTER BED ❑ Distance to nearest: Well. Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS 17' 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 remploy 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. ` Signed X Title:)M - �,� -1 M 0LU L6� Date: 4 011 FOR DEPARTMENT USE ONLY Application Accepted by Date &-- u // Pit or Grout Inspection Date Final Inspection by Date Additional Comments: El Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT'DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH ��P7 F + EH 13-241REV.f 5) EH 1426 ' r f