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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address r City Lot Size PM ` .Ow, 309 ner's Name Address & ._ Phone Ag ContracE L+l�il;: Address License No. 27(P Phone OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT ❑ DESTRUCTION El PUMPIIf STALLkhON.Ll� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARE TIC TANK SEWER LINES pISPOSAL FLD. PROP. LINE FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL _P_MY56EW AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Ll Manteca a. of Well Excavation Dia. of Well Casing t i ❑ Domestic/Private ❑ GravelPack. ❑ Tracy LL - Type o Specifications ❑ Puhlic, El Other ❑ Delta..,- ,R,epth of Grout Seal Type of Grout ❑ Irrigation _-.__Approx_ Depth' ❑ Eastefh Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well ,estruction ❑ Well Diameter Sealing Material 1top 501 Y Depth _ _-- __ _,;,1 Filler Material (Below 50`) _ TYPEIOF SEPTIC WORK: NEW INSTALLATION REPAtR/AOOITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I /� available within 200 feet.) t Installation will serve: Residence 1' Commercial �;__Other4 r_ S Number of living units:—I— Number of drooms Character of soil to a depth of 3 feet: Water table depth SfPTC TANK J�Type/Mfg f Capacityt � No. Compartments PKG_`TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well Foundation �Q-:. Property Line �S t.LEACOING LINE J NO,;& Lengtl'`of lines.;