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L 4 I APPLICATION FOR-PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ,. 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joo�quin 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 Regulatio s of the San Joaquin Local Health District. ��6/'- - -7` 02- Job Address 29357 ]vast Orange City Esca(lon Lot Size PM Owner's Name Mr-Jim Chipponeri Address 29357 East Orange Phone $38-3769 C�O Contractor's Name Martin Pump & •Supple;License No. 360-851 Phone 847-0394 I } TYPE OF WELL/PUMP: NEW WELL CK WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ® SYSTEM REPAIR-® OTHER ❑ ,--� DISTANCE TO NEAREST: SEPTIC TANK 100't SEWER LINES 90 r DISPOSAL FLO._90'_ PROP. LINE 100' FOUNDATION 100' AGRICULTURE WELL None OTHER WELL 75=' PITS/SUMPS None INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ElManteca t "Dia. of Well Excavation Dia. of Well Casing 6 5/8 M Domestic/Private 103 Gravel Pack ❑ Tracy Type of Casing Ste41 Specifications ❑ Public ❑ Other ❑ Delta _Depth of Grout Seal 501 Type of GroutBentonite E fi ❑ Irrigation --Approx. Depth ElEastern ,`Surface Seal Installed by Martin PUMR & Supply-Inc Repair Work Done ❑ Type of Pump Subm H.P. { 1 State Work Done Q Well Destruction 13Well Diameter. Sealing Material (top 50') Depth Filler Material (Below 501, ba TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 'REPAIR IADDITION ❑ -DESTRUCTION ❑ (No septic system permitted if public sewer is \3'+ available within 200 feet.) t Installation will serve: Residence_ Commercial! Other Number of liming units: Number of bedrooms �'! ! Character of soil to a depth of 3 feet. A Water table depth SEPTIC TANK ❑ Type/Mfg 's' Capacity No. Compartments PKG. TREATMENT PLT. ❑ _4,+:-- } Method of Disposal Distance to nearest: Well Foundation Q Property. Line LEACHING LINE ❑ No. & Length of lines .-Total_IengthZs1zA FILTER BED ❑ Distance to nearest: Well Foundation i Property Line r SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I t 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: "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 applica ust call for all req'uiirred)nspecttiion,.s.fCo/plate drawing on reverse sid� / Signed X� `Z � . �I s L��L9 Title: ( �if-A ? Date: � .f i•:; i �.r s FOR D RTMENT FUSE`ONLY p Application Accepted by Date Area fes, Pit or Grout Inspectionby Date�� Final Inspection by Date Additional Comments: # r ❑ Stk 466-6781 ❑ Lodi 369-3621teca 823-7104 El Tracy 835-6385 Applicant- Return all copies to: Envirolill' ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 CK -�_ INFO AMOUNT DUE '' AMOUNT REMITTED CASH RECEIVED BY DATE +rfPEIT`N0. + EH 13-24(REV 101831 cj g� - 1 \ � '�a3`-�'T EH 14-28 (vvvJI M�