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f APPLICPATION"FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " (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 1'made in compliance with San Joaquin County Ordinance No.549 for sewage of No. 1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. k { Joh Address 3125 E. Orange Street city `Acaxnpo Lot Size 10,000 sq.ftPM � Owner's Name San Joaquin County Address 1810 E. Hazel tori Avenue Phone g44-2281 . Public Work's Department Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL 13 WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES NSA DISPOSAL FLD. PROP. LINE 25" FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation 24" Dia. of Well Casing 20" ❑ Domestic/Private 91 Gravel Pack ❑ Tracy Type of Casing Steel Specifications Attached 1'� :K Public ❑ Other a1 ❑ Delta Depth of Grout Seal 100min- Type of Grout Cement grout ❑ Irrigation 45W4pprox. Depth ❑ Eastern Surface Seal Installed by Contractor Repair Work Done ❑ Type of PumpSubmersible H.P. 40 State Work Done O Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 17 DESTRUCTION El1No septic system permitted if public sewer is Installation will serve: Residence f[ Commercial_ Other available within 200 feet.l Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ a Method of Disposal Distance to nearest: Well Foundation Property Line E LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line + DISPOSAL PONDS ❑. 1 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 shall not i employ any person in such manner as to become subject to workman's compensation laws of Califomia." Contractor's hiring or sub-contracting signature 11 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- tion laws of California." s The applicant mus call for all requiredinspe ions. C mplete drawing on reverse side. D Signed Title; Director of Public Works Date: Za a HEN Y tj HI TA FOR DEPARTMENT USE ONLY Application Accepted by ry Date 2 `� Area � * t7 Pit or Grout Inspection by Date h+ u' final Inspection by Date Additional Comme . 4 •_W.A � Z ❑ Stk 466-6781 _ - i_.-*&3621 anteca 823-7104 Cl Tracy 835-6385 rJr �f r�ty�ac.c Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t, FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. ,. INFO jVII/ +'EH13-241REV.5/e5) X53 c -7 EH 1420 t