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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ��- 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone-(209) 466-6781 ► } �� ./his""' I PERMIT EXPIRES.1""YEAR,FROM DATE ISSUED v. . ,.. {Complete.m Triplicate) �} —II �C v Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein ribed.This application is F made in compliance:Wth 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..�0i� �t�• EsCalon 4 Job Address 22650 South ,HenryA rt City Lot Size w PM _ - __.."_ _3006 _ w _ . _,— _.. ._ 5 ` er w Owner's Name Mr'Robert--Olsen Address East Le Phone MOB 360--851 847-0394 l Contractor's Name Martin Pump &'Supply License No. — _ Phone i TYPE OF WELL/PUMP: NEW WELL EWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION.JE SYSTEM REPAIR El OTHER ❑ 40 DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES DISPOSAL FLD!L !� .PROP. LINE .._. FOUNDATION _ �— AGRICULTURE WEL OTHER WELL&O—P PITS/SUMPS �INTENDED USE, TYPE OF WELL PROBLEM AREA CON TS RUCTION SPECIFICATIONS ,❑ Industrial � ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 65/8 .IX Domestic/Privet e'N (S Gravel Pack ❑ Tracy Type of Casing—--,%t PP 1 Specifications ❑ Public r ❑ Other ❑ Delta Depth of Grout Seal - r Type of Grout nit ❑ Irrigation? - --Approx. Depth ❑ Eastern S ace Seal Installed by' Repair Work Done ❑ Type of Pump ._ H•P• State Work Done r, N well Destruction EIr Well Diameter Sealing anal two 50'1 QDepth Filler Material (Below 501 k - TYPE OF SEPTIC WORK: INEW'INSTALLATION ❑ REPAIR/ADDITION ❑ 0EESTRUCTION El (No,septic system permitted if public sewer is-n L .. _ available within 200 feet.) A.;6 t Installation will serve: .Residence Commercial_ Other # jf : VI Number of living units: Number ofrbedrooms= � v� P "Character of soil to a depth of 3"feet: s.. t ' ' \1/ Water table depth r' Capacity— SEPTIC TANK E] Method of Disposal Type/Mfg '" r I ity No. Compartments PKG. TREATMENT PLT. F1 T [ > Distance to nearest: Well Foundation Property Line s + r� � LEACHING LINE t❑ .�No. & Length of lines Total length/ FILTER BED #"' #❑ Distance to nearest:, Well Foundation Property Line SEEPAGE PITS ❑ Depth Size `" ' Number . r ` L' SUMPS r ❑ [Distance to nearest: Welt' r -Foundation ., Property Line .DISPOSAL PONDS ❑ ' hereby certify that I have prepared this application and that the work,wlll be done in accordance with San Joaquin county ordinances, state lawsr'and rules and regulations of thetan Joaquin Local Health District. + w° i. 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! 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- ition laws of California.".- '} !- (+ The appfica us call for all, uired inspections. Complete drawing on reverse side. l Title: _ Date: Signed > FOR TMENT USE ONLY E Application Accepted by Date Area �] p Date /�J Pit or Grout Inspection DaterZ� Final Inspection by Additional Comments: i ❑ Stk' 466-5781 i-' ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 : RELY- I —FEE'.OUNT DUE AMOUNT REMITTED CASH IVED BY DATE PERMIT"NO. INFO til + EH 13-24IREV.10/83)- }. { �- ©3.• I �Q - EH 14-26 -.. .. . _