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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZE,i ON AVE., STOCKTON, CA f Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cornpiere iri{Ttipilcate) 1 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 t made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rutes and Regulations of the San Joaquin Local Health District. Job Address 17128 S . SteineguI Road Cityescalon Lot Size PM Owner's Name # rAddress 1 7 1 7,8_ c S t-r� i n p g_u_Lrf Phone 8 3 8 - B 4 4 Contractor R i c ft a r d G Address License Noa - b 4 4 L 8 6 R Phone TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT Ci DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r L-i Industrial G Open Bottom 1 Manteca Dia.,of Well Excavation Dia. of Well Casing F Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications I 1"i Plibfic R Other Delta Depth of Grout Seal Type of Giout I ! Irrigation ._Approx. faepth I I Eastern Surface Seal Installed by Repair Work Done fA Type of Pump H,P. State Work Done_ We#I Destruction ❑ Well Diameter Sealing.Material (top 50') Depth Filler Material ISelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 131 REPAIRIADDITfON I I DESTRUCTION 1 1 INo septic system permitted if public sewer is I Instafavailable within 200 feet.) Number will serve: Residence x Commercial� Other I Number of living units: 1 Number of bedrooms 3 . : Character of soil to a depth of 3 feet: hard pan - Water table depth + SEPTIC TANK k] TypelMfg P & I- f Capacity_2 f] f1 (] ,q-21A No. Compartments 2 r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well J 0 f tFoundation ? 5 f.f:_ Property Line 5 0 0 f t I _0 _ LEACHING LINE gl No. & Length of lines 2 Total length/size 1 5 0 f t X 2 ft w i d e FILTER BED ❑ Distance to nearest: Well 40 Foundation d_O Property Line "4 4 f SEEPAGE PITS VX Depth r C. P L�� f t __Size _.2_0_f L_1 Number� P— a1,1�� [& .CA SUMPS L'I Distance to nearest: We11.90 0 Foundation 1.0 0 Property Line DISPOSAL PONDS F1 i I hereby certify that f 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 became 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 appiican st llflelriod inspections. Complete drawing on reverse side. �f Signed X_ Title: _ P�1i~— _ Date: Z40R DEPARTMENT USE ONLY Application Accepted by 6 Date rea (J Pit or Grout Inspection by Data Final Inspection by # Date Additional Comments: } ❑ Stk 466-6781 1 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE aPERMIT'NO.11q ��.f'� CASHEH 1324(REV.i n 7k CRI � C..aC7 - 1 EH 14.28 e] � ; ' (S 14 (1 0 1