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APPLICATION FOR PERMIT _wr 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 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 21664 E River'gmd city Escalon Lot Size / S PM Owner's NamRick Dodge Address 433 Altrinnrl C-T (Ripon) Phone — Contractor. Martin Ptmm Is S144�Address 5 Rip-M Rnad� i License No. 360-851 Phone - TYPE OF WELL/PUMP: NEW WELL"2. WELL REPLACEMENT ❑ DESTRUCTION ❑I PUMP INSTALLATION 13 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK NnnF SEWER LINES TNme DISPOSAL FLD1X 1ePROP. LINE 21W �F FOUNDATION Ncdae - AGRICULTURE WELLNnne OTHER WELL• 1\3D PITS/SUMPS None r INTENDED USE TYPE OF WELL"" ,PROBLEM AREA',•CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑'Open Bottom r, ❑ Manteca �bia.of Well Excavation 11 Dia. of Well Casing 6 5 8 * Domestic/Private ®"Gravel Pack ❑ Tracy Type of Casing Steel Specifications t { Public ❑ Other n.-Delta Depth of Grout Seal 50' Type of Grout BentOnite _ l i irrigation _..Approx. Depth I-I:Easteffi— 'Surface"8eal-I6sf3llad ti-y' Repair Work Done [X Type of Pum p yp p _Subm: H.P. X 3 State Work Done Well Destruction ❑ Well Diameter r Sealing Material (top 501 Depth "�f# � Filler Material (Below 50'1 ` TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION I i (No septic system permitted it public sewer is { I available within 200 feet.) f 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r } LEACHING LINE ❑ No..,& Length of lines Total Length/size FILTER BED ❑ , Distance to nearest: Well Foundation Property Line SEEPAGE P4TS l I Depth Size _ Number SUMPS ❑ Diistance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ r I hereby certify that I have prepared this appli66tion 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 I 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 t call for all required i spections. Complete drawing oh reverse side. t Signed X dle: l �� ., Date: FOR DEPARTMENT USE ONLY r Application Accepted by Date � ��^ Area f� $ Pit or Grout Inspection by Date �r5w BAgnspactionf b DateU ll Additional Comments: ❑ 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 I � INFO -iCAMOUNT DUE AMOUNT REMITTED CK 0 ASH RECEIVED BY DATE PERMITNO. +.EH1324IREV.vH5) EH 10-28 11 - {l