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b; APPLICATION FOR PERMIT hud 6ct� IIS 7 G- SAN JOAQUIN LOCAL HEALTH DISTRICT �e , 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6181 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - y (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/ and the Rules and Regulations oft a San Joaq Local Health District. / 2 �(�Ii i LCIT o (jL'P��- Job Address 2�� Santa Fe cityEscalon Lot Size_- PM Owner's Name PIK S Kathy Cook Address 118 Idahl Phone - "' tor's NameIt74oense No. 3��1 R Y _ Phone Cont a ry - TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ N PUMP INSTALLATION .® SYSTEM REPAIR ❑ OTHER 11 DISTANCE TO NEAREST: SEPTIC TANK110AKI SEWER LINES 0AJC DISPOSAL;FLD—L --- EROP. LINEfa WELL ..n� A1 FOUNDATION - AGRICULTURE WELL '� OTHER vS�i3-[��J& PITS/SUMPS INTENDED USE: TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( 8 ❑ Industrial ❑ Open Bottom E] Manteca Dia. of Well Excavation Dia. of Well Casing CX Domestic/Private ® Gravel Pack If Tracy Type of Casing Steel Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 50; Type of Grout ❑ Irrigation ---Approx. Depth El Eastern Surface Sea! Installed by ~? Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is 3 available within 200 feet.l 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�TM l} SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Pr6perty Line LEACHING LINE i ❑ No. & Length of lines ' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line rI SEEPAGE PITS ; ❑ Depth Size Number SUMPS 1 ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ w l I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin icounty 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-forwhich•this-permit-is-issued;I-shall-employ-persons subject to workman's compensa- tion laws of Caldor The applicant call for all req 'ed ins ons. Complete awing on verse side. Signed Title: y v'• rl Date: FOR DEPARTMENT USE ONLY f Application Accepted by -Date �` Area Pit or Grout Inspection by Date Final Inspection by Date ( —Z- feel'a 7d7�1r�7[or3Gi' Additional Comments: - trvf — w-G1/ Y►u 1- vn F-I Le T 1 u - c4i ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 k1el Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f " FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"'N0. INFO {},� CASH p {�� + EH 13-24 1REV.101831 X au �i5"! EH 14-28 (3 !