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APPLICATION FOR PERMIT �b 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 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 18708 Sutliff Road City Escalon Lot Size 30 acers PM Owner's Name Mr NOrfnan Silva Address 18708 Sutliff Road Phone W-2352 Contractor Martin Pump & SP lyAddress 5 Reed Road License No. 360-851 Phone 847-0394 TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION 99 SYSTEM REPAIR ❑'� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 50' SEWER LINES 501+ DISPOSAL FLD. 50 PROP. LINE 75' FOUNDATION 50' AGRICULTURE WELL 110 a OTHER WELL �O r PITS/SUMPS brie INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 11 Dia. of Well Casing 5/8 0 Domestic/Private k) Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other {l Delta Depth of Grout Seal 50' Type of Grout Bentonite _ I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done C Type of Pump Subn H.P. 1 lA State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material f Below 50.1 O TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION [ I (No septic system permitted if public sewer is available within 200 feet.) 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 r Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 6tal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r" -0- SEEPAGE PITS { I Depth Size f Number SUMPS ❑ 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 acco_rda�n,ce•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 Ca€ifornia.-"-Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit) issued)'!shall employ persons subject to workman's compensa- tion laws of California." The applica st call for all re wired ins c iortns.//CompI to drawing on averse side. , Signed ✓��YL r7f.> Title: � + pate: C� } EP T NT USE C!IVLY' Application Accepted by a Date Area 4. Pit or Grout Inspection by DateFinal Insped"ti -by i` Date - � Additional Comments: G� . �+�. !/�S ✓�X.�rf �/�'yi ❑ Stk 466-6781 ❑ Lodi 369-3621 �'❑'Manteca 823-7104 ❑ Tracy 835- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k� PEE AMOUNT DUEAMOUNT REMITTED —CK INFO AS RECEIVED BY DATE PERMIT N0. s +.EH 1324(RE'.1/a 51 EH 14-26 - _ Z