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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone .(209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) SUN 1��7 <br /> Application is.hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein des <br /> T",Apluion is <br /> made in compliance with San Joaquin Co'my Ordinance No.549 for sewage or No. 1862 for well/pump and the Ru19 'Okk�tJ f( n Joaquin <br /> Local Health District. PER <br /> f <br /> Job Address City Lot Size PM <br /> • <br /> Address <br /> Owner's Name v Phone <br /> Contractor 0Y✓ QJ' Address License No.jgf <br /> J'7G/ r Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ r <br /> PUMP INSTALLATION �C, SYSTEM REPAIR OTHER ❑ t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. D SPOSAL FLO. PROP. LINE <br /> _.FOUNDATION _ AGRICULTURE WELL OTHER WELL PiT51SUMP5 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> ❑ Industrial ElOpen Bottom ❑ Manteca Dia. of.Well Excavation Dia. of Well Casing <br /> WDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> n Public ❑ Other M Delta Depth of Grout Seal Type of Grout — <br /> I I irrigation --Approx. Dep /1 I Eastorn Surface Seal Installed by <br /> t Repair Work Done ❑ Type of Pun Sk±4 _— H.P. S4Q ,4d State Work one <br /> f Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth �S7 Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i l REPAIR/ADDITION l I OESTRUCTION l 1 INo septic system permitted if public sewer is 1 <br /> . � <br /> available within 200 feet.) <br /> Installation will serve: Residence r" Commercial y Other N <br /> Number of living units: Number of bedrooms 1 r p <br /> r Character of soil to a depth of 3 feet: Water table depth w <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> w* + PKG.•T.REATMENT PLT..❑. - - M i � --,Method of Disposal. <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ - No. & Length of lines Total,length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line # <br /> , t 8 , <br /> iF I <br /> SEEPAGE PITS C I Depth Size (Number <br /> ❑ • Distance to nearest:" Well Foundation_ Property <br /> a SUMP-S "e t t. <br />