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APPLICATION FOR PERMIT I <br /> - <br /> SAN JOAQUiN LOCAL fHEALTH DISTRICT <br /> 1601 H. HAZELTON AVE., STOCKTON, CA PERMIT NO, <br /> Telephone (209) 466-6781 1 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a pennit'to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump j <br /> and the Rules and Regulations of the San Joaquin Local Health District. - P <br /> Job Address x'0366 GfjrYOl.To/Y IV Subdivision Name <br /> Owner's Name C 5-/A1Ake,5 Address .2 3G[ CA4- �f. Phone <br /> Contractor's Name 5v1V License No, Phone <br /> 4 <br /> TYPE OF WELL/PUMP WORK:." NEW WELL ❑ WELL REPLACEMENT '❑ DESTRUCTION ❑,, <br /> t- PUMP IIVSTRLLRT.ION�❑.�. - SYSTEM..REP.AIR �j. --OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " <br /> Industrial ❑ Open Bottom :.❑ Manteca Dia. of Well Excavation t <br /> ❑ Domestic/Private ❑Gravel Pack, A ❑Tracy Dia. of Well Casing ! <br /> Public Oter ea i <br /> ❑ ❑IhDlt <br /> ❑ Type of Casing i <br /> Irrigation '—r Approx. Eastern <br /> Specifications �' r <br /> F-1CathodicProtection N�Dep th <br /> Depth of= <br />