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r:bY APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA � Telephone (2091466-6781 _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 wellipump and the Rules and Regulations of the San Joaquin Local Health District. Jot) Add,ve,� 9200 Temple Creek Road CityEscaIon Lot Size 40Ox300 pM Owner's Name Gerald Lawler Address 1821 White Berch Rd. H h n Phone 883-0680 Contractor. Address. 7900 Wren Rd. Oakdale License No. A-B 441868Fhone 847-3480 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PiTSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Induslna# ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E., Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications f•1 Public n Other - ❑ Delta Depth of Grout Seat Type of Grout ! Irrigation __.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Li Type of Pump H.P. State Work Done _ Well Destruction ll Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION IX) REPAIWADDITION 1 1 DESTRUCTION I i (No septic system permitted if pubic sewer is available within 200 feet.) cIL] lnstallation will serve: Residence x Commercial_ Other O Number of living units: 1 Number of bedrooms 5 Character of so4 to a depth of 3 feet: a gravel Water table depth 10O # SEPTIC TANK []iI Type/Mfg p&i concrete Capacity 2000 No. Compartments 2 PKG, TREATMENT FLT. ❑ Method of Disposal 1 e a C h l n& Pits Distance to nearest: Well AW Foundation 20Property tine 150' LEACHING LINE tdil No. & Length of lines 4 @ 50 ' _ Total lengthisize 200 1 i n.f t .1 4 0 0 s q.f t . . r C FILTER SED EJ1 A..Distance to nearest: Well� Foundation Property Line 71 b SEEPAGE PITS [A Depth 2 51 - Size 480 Number 4 SUMPS LI Distance to nearest: Well 164 , 'Foundation -_75' ____ Property Line -_ 150' 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 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: -1 certify that in the performance of the work for which this permit is issued, €shall employ persons subject to workman's compensa- tion laws of California." The applicant t c II for rej 'red inspections. Complete drawing on reverse.sid�e/. Signed X Title: &t�1'/ � Date: d Q Ar—Al 00, �.. 4\^,' 0 EPARTMENT tJSE ONLY Application Accepted by �ln.... �. Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: l Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca" 823-7104 ❑ Tracy 835-5385 Applicant - Return all copies to: Environmental Health Permit/Services 1W1 E. Hazelton Ave., P.O. 'Box 2009, Sik., CA 95201 INF AMOUNT DUE AMOUNT REWT',, D CK RECEIVED BY DATE PERM11 NO EH 13.26(REV . rW}! lszs -del15,1 f