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APPLICATION FOR PERMIT /V fir " SAN JOAQUIN LOCAL HEALTH DISTRICT 5 / � 1601 E. HAZE` TON AVE.,1 STOCKTON, CA Telephone d (209)/466-6781 , µ PERMIT EXPIRES i YEAR FROM DATE ISSUED {Complete jn Triplicate) ._ Application is hereby made to the San Joaquin Local Health District fora rT dD or 3 DO 'O made H compliance wit an oaquin ounty Qrdinance No.549 for sewage No. 1862for well tlpump andnstathe work the ales and Regulations of the San J Loco! Health District. - described• This application is � OaQUIn 6fi /4C1 Job Address E. e d City Acampo Lot Size 13,900 sq ll f t PM Owner's Name San 7oacxun Count �� �' Address 1810 .E. Hazelton Avenue Public Works Department Phone 944-2281 Contractor Address TYPE OF WELL/PUMP: NEW WEL ® License No. L Phone'l WELL REPLACEMENT ❑ DESTRUCTION ❑ -� PUMP INSTALLATlA� SYSTEM REPAIR ❑ I � DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ I� SEWER LINES FOUNDATION DISPOSAL FLD, PROP. LINE 125, AGRICULTURE WELL INTENDED USE OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L # ❑ Industrial ❑ Open Bottom i R ❑ Domestic/Private C1 Manteca Dia. of Well Excavation 24" Dia. of Well Casing 20" 4 ',I ® Public Gravel Pack ❑ Tracy Type of Casing Steel E ❑ Other ❑ pelta Depth of Grout Sea! 100' min. Specifications Attached + G f2 Irrigation 4$0 CiI Type of Grout Cement rout op . .` �Approx. Depth ❑ Eastern Surface Seal Installed by Contractor M Repair Work Done ❑ Type of Pump SubmersibleH p 40 State Work i Well Destruction ❑ Well Diameter Done f P Sealing Material flop 50') Depth t# Filler Material (Below 50') j TYRE OF SEPTIC WORK: NEW INSTALLATION LJ Filter ❑ DESTRUCTION ❑ iMo septic system permitted if public sewer Is Installation will serve: Residence, Commercial— Otheravailable within 200 feet.) I _ ; Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth it acy�� f PKG. TREATMENT PLT. ❑ CapNo. Compartments Method of Disposal Distance to nearest: Well Foundation Property Line i' V LEACHING LINE ❑ No. & Length of lines FILTER BED Total length/size ❑ Distance to nearest: Well Foundation property Line I SEEPAGE PITS ❑ DepthIr , Size SUMPS EJ Distance Distance to nearest: Well DISPOSAL PONDS ❑ Foundation Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinancesp state laws, an ' IEE rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify ' employ any person in such manner as to become subject to workman's compensation lawsofCaliforrnia,"Contractonce of the work for r`slh ringch 'or sub-contracting ngl gnaltur L certifies the following:"1 certify that in the performance of the work for which this tion laws of California." permit is issued,I shall employ persons subject to workman's compensa= The applicant mus call for all required ins actions, Complete drawing on reverse side. Signeds Director. of Public Work / Ili HENRY M HIRATA Title: Date: / Z IJ FOR DEPARTMENT USE ONLY C Application Accepted by v �! Z /G's�7 , �Z Pit or Grout Inspection by Date Area Date Final Inspection by�� p pp Additional Com nts: 4J ;� rz7�- Date ? C�--t 2 ❑ Stk 466-678 1 86 6781 odi--369=362 C1 Manteca 823%104II Applicant- Return all copies to: Environmental Health Permit/Services /601 E. Hazelt n AvTracy g exp O- a S4f CA 95201 - FEE EH 13-24IR�. INFO AMOUNT DUE AMOUNT REMITTED C .. RECEIVED BY DATE PERMIT NO + i/a 5) l EH/426 c, 5