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APPLICATION FOR PERMIT 5q + SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) s 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. Escalon Ranch Colon S.W. corner of tLone-T_ree_Rd� & Henry Rd. , Escalon I Job Address } City Lot Size PM i Owner's Name Zagaris Management 5drvicIR5dr ss P,Q, Box 3263, Mode-efto — Phone Contractor Hennings BROs. 1 Address 8525 ReIandale, Mod. License No. 290813 Phone 1 1185 i -545 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION CROP. I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERt Hole & water DISTANCE TO NEAREST: SEPTIC TANK none SEWER LINES DISPOSAL FLD. NE samples FOUNDATION AGRICULTURE WELL OTHER WELL PS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 E) Domestic/Private X1 Gravel Pack ❑ Tracy Type of Casing tee I Specifications 3011 conduct r A Public 171 Other M Delta Depth of Grout Seal 10o I _ Type of Grout & Cem n I I Irrigation _-.Appro0Depth I I Eastern Surface Seal Installed by driller { Repair Work Done 0 Type of Pump H.P, State Work Done Well Destruction ❑ Well diameter Sealing Material (top 501 Depth Filler Material (Below 50') __ N TYPE OF SEPTIC WORK; NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION ( I Wo septic system permitted if public sewer is s 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 Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. $ Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I-hereby certify_that.:1_have:prepared4hiskappiication-and-that-thework=will-Be done in accordance with San Joaquin Jounty ordinances, state laws, and I rules and regulations of the San Joaquin Local Health DFstrict. 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 signatur I 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X Hennings Bros. By Title: 00 Date: 8-1-90 F R DEPA MENT USE ONLY Application Accepted by Date Q Area Pit o rou Inspection by Date07v (nal Inspection by Date 54 Additional Comments: O2 i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 JFEI Tracy 835-6389- Return all copies to: Environ}mentat Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201FEE �P4' I INFO (O/UNT DUE A OUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH14-24(REV.i/x 51 EH 14-28 J26 104FZT- at �—