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bfif haF-Sl-4u, t,.Lll 11r:(� Yf-`1' , APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4-ov we{ y 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (2W 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r J" (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 fo�sevrage or No.1852 for waltlpump and the Rules and Regulations of the 6�oagyjr}�. Local Health District, Z!5-U 2. /�(i i t ^�tot b� �(pa_ p 2��`L Santa Fe 7 t cityEscalon Lot Size c � L��Jv l PM Job Address owner's Name 14r Kathv Caok Address I Idahl Phone Phone - ---- ^ - �-_;t ;ti Putnli& Su 1vM nM:�onse No, Contractor's NameM PP TYPE OF WELL/PUMP: NEW WELL 9 WELL REPLACEMENT O DESTRUCTION ❑ OTHER ❑ PUMP INSTALLATION -S SYSTEM REPAIR O ,,,•�� / a DISTANCE TO NEAREST: SEPTIC TANKIJQA ' SEWER LINES �E. DISPOSAL,FLDNO�e- eROP. LINE`J�1 O FOUNDATION r AGRICULTURE WELLM_ 2__ OTHER WELL PITS/SUMPS INTENDED USE; TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 $ 1 -IF-- Dia. of Well Casing El Industrial G Open Bottom ❑ Manteca Dia. of Well Excavation (M DomesticlPrivate ® Gravel Pack G Tracy Type of Casing Steel Specifications— ❑ Delta Depth of Grout Seal 1 501 Type of Grout ❑ Public ❑ Other �y 4 ❑ Irrigation _--Approx. Depth ❑ Eastern Surtace Seal Installed by Repair Work Done O Type of Pump H.P. State Work Done Well Destruction W Well Diameter Sealing Material I=50') , Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION G Mo septic system permitted if public sewer is available within 200 feet.), 3 Installation will serve: Residence Commercial_ Other t Number of living units: ,Number 9f bedrooms -� t Character of soil to a depth of 3 fest: SEPTIC TANK O Type/Mfg Capacity—_ - Water table depth ' No. Compartments PKG.TREATMENT PLT. El _ - - - `. Method of Disposal Distance to nearest: Well Foundation Proparty Line LEACHING LINE i ❑ No. & Length of Vines Total lengthtsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS { ❑ Depth Size Number SUMPS f ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 shell not employ any person in such manner as to become subject to workman's compensation laws of Califomia."Contractor's hmng or sub-contracting signature certifies the folkmdng,.-I certify-that-in the•performance-of the work-fbr whioh this permit•isassued,I-shallemploy-persons subject to workman's compensa- tion laws of Califor ' The applicant m call for all req ad i ons, Compipteilrwing on ♦♦versa side• /A►/q` f�f e Signed Title: _ '� "' ' T '` 7 - date: USE ONLY FOR DEPARTMENT / Application Accepted by -Date f �✓ ,, r Pit or Grout Inspection by Date Final Inspection by Date —zr��t'a� �.t-Y4d�.. 3,a�3�;Ar,V s�� Additional Comments: 9�+^v c" y yf 1 sr� ►-u-v f" t.cc( r''v r `-fiL�i�c C Stk 466-6781 ❑ Lodi 369-3611 EI Manteca 823-7104 C1 Tracy 835-63> i �-2 �YvS f S Applicant-Return all copies to: Environmental Health PenTk/Services 1601 E. F}tetelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT h10. INFO Qtr c + VY EH13241REV.t�1831 EH 1-0.28