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APPLICATION FOR PERMIT M SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA r 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. ; G. Job Address 31 1 10 '.E. - LEE city E S C A L CIN Lot Size PM Owners Name CHESTER S M'I T H Address 31 1 10- E .• LEE E S C A L 0 N phone 869- 1126 1. contractor H E N N I N G S BROS . Address 3525 P E L A N D A L E A V E�icense No.290813 Phone 545- 1185 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Q DESTRUCTION ❑ PUMP 4NSTALLATION_❑ _ -SYSTEM REPAIR ❑ OTHER ❑ O DISTANCE TO NEAREST: SEPTIC TANK 100 r + SEWER I ES 1 O 0 + DISPOSAL II PROP.LINE" FOUNDATION AGRICULTURE WELL OTHER WELL-74-!. PITS/SUMPS (1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v ! ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Casing f EX Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVCSpecifications ❑ Public ❑ Other 1 1:1Delta Depth of Grout Seal 50 , Type of Grout BE TONITE ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by HENNINGS BROS. Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material (Below 501 YPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 7 available within 200 feet.] i Installation Residence Commercial Other Number of living units: bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg apacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation rty Line LEACHING LINE ❑ No. &, Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS ❑ Depths Size Number iw - _ -- � -..» .. . SUMPS ❑ Distance to nearest: Well Foundation Property Line `" '� DISPOSAL PONDS ❑ J 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 r 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." I i The applicant must call for all required inspections. Complete drawing on rev rse side t s Signed XWA�Y�J� d��. -O"`�-J Title �.._ Date: — ` -� t FOR D PARTMENT SE NL Application Accepted by c Date ! ! Area �✓![�i Pit or Grout Inspection by Date` Fin I Inspection by /t Date la 1 Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return ail copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t f� OLD cv,61-L A,��s zFe;o loe"Po. FEE C INFO AMOUNT 60E AMOUNT REMITTED CK H RECEIVED BY DATE PERMITNO. + EH 13-244REV.i/e 57 .;:. . � - 4l.ly� 1_►ZL9 G�1�"L�$"� �—�SU 1 - EH 1428 1 1{{