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APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is made in compliance with San Joaquin County Adinance No.5499 for sewage or No. 1862 for well pump and the Rules and Regulations of the San Joaquin Local Health District. I (//( 1 111 11 4 $scalon — Waste Water Treatment Plant City Escalon Lot Size PM Job Address Owner's Name City of Escalon Address P.O. Box 249 Phone 209 838—8045 Wester Address P•0• Box 1664 License No,552198 Phone(916)373-111 Contractor—_�— TYPE OF WELL/PUMP: NEW WELL 13 WELL REPLACEMENT ❑ DESTRUCTION R EI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 3"® industrial El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing Type of Casing PVC Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout CeTcieut i`l Public l-1 Other ❑ Delta Depth of Grout Seal I I 1 irrigation SaApprox. Depth hal Eastern Surface Seal Installed by Driller Repair Work pone ❑ Type of Pump H P State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth Filler Material j8elow 501 �— '� TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I i DESTRUCTION I I (Nose ttic system relined if public sewer isavaila \�\y eet Installation will serve: Residence— Commercial— Other ` Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK D Type/Mfg Capacity No. Compartments ^ 1-1Method of Disposal PKG. TREATMENT PLT. Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 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 Oiltrict. 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 re ired inspec' ns. Complete drawing on reverse side. _ Signed X. Title: fO C f?�S �' pate: — FOR EPARTMENT USE ONLY Date___L� r Area l Application Accepted by �JL �� Date G Pito®routinspection Date Final Inspection by�; -.— _ t71-a Additional Comments: ❑ Stk 466 6781 171 Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 635 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE OUNT R ED RECEIVED BY DATE PERMIT NO. INFO {p /r . EH 13-241REV.5/n 5) �\ 41D EH N-26