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APPLICATION FOR PERMIT 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 _7122 Seidner City Escalon Lot Size 25 Acers PM Owner's Name TWS Enterprises, Inc Address 20600 Sutliff Road Phone 838-7147 Contractor's Name Mgrtin Putti & Su 1 License No. 360--851 Phone 847•-0394 TYPE OF WELL/PUMP: NEW WELL T WELL REPLACEMENT ❑ DESTRUCTION ❑ —PUMP INSTALMTION-IKII— '"°` SYSTEi 4 REPAIR ❑' " OTHER'-D'—_---' DISTANCE TO NEAREST: SEPTIC TANK 100'+ SEWER LINES 1001+ DISPOSAL FLO.100 t+ PROP. LINE 100 FOUNDATION 30t AGRICULTURE WELL 1Vone OTHER WELL None PITS/SUMPS Norte INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6 5J8 k] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steitl Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 501 Type of Grout Bentonite ❑ Irrigation ---Approx. De th ❑ Eastern Surface Seal Installed by N, Repair Work Done ❑ Type of Pump � H.P. �.✓rop State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') r' Depth Filler Material Melow 50') M 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 C1.. Number of living units: Number of bedrooms •"' 1 E 1 Character of soil to a depth of 3 feet:"""" """ Water table depth • SEPTIC TANK ❑ Type/MfgT Capacity No. Compartments T PKG. TREATMENT PLT. ❑ A f Method of Disposal Distance to nearest: -Nell Foundation Property Line r L LEACHING LINE ❑ No. & Length of lines `r„� Total length/size f FILTER BED r .❑ Distance to nearest: Well f `Foundation Property Line / 1 4 SEEPAGE PITS _ I❑' Depth Size Number SUMPS 1.--h T !❑ Distance to nearest: ' Well Fouridation f Property Line DISPOSAL PQNDS__ 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." 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 applicanta I for all required inspections. Complete dr 'ng on reverse side. , Signed _ itle: ��d . ?/1,�j� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area L �� J c 6' .f a w Pit or Grout Inspection by DateFinal Inspection by Date - 3�LJ—�S ..w-r7©>` V/lr ri61�oi�6-d6wn. ci-«�crJ lulc c5- o: x 2 --CES t 4. 11 ha-d 6-�t�. Additional Comments: w 1 4-a t e V+.-,J 4y r,, p „ga,rl� ►�5r{c , G a4lcev C e*_eyf C,6-L±y D Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-8385 Applicant- Return all copies to: Environmental ea h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 T FEE t NFO TAMOUNT O E"'' AMOUNT'REMITTED CASH RECEIVED BY' DATE- '-PERMIT"NO— r' + EH 13-24 4REV.16/831 C S 3-) EH 1426 ��