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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �\ 1601 E. HAZEL T ON AVE.,,STOCKTON, CA V Telephone (209) 466-6781 t PERMIT EXPIRES i 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' he San Joaquin ' Local Health District," �� \]/ Job Addres * , ity �7 Lot Size PM Owner's Name Address J 6� Phone —d Contractor - r � , es s "`'-r License No. �/ s' �Dphone z TYPE OF WELL/PUMP: NEW WELL ED REPLACEMENT DESTRUCTION 1 PUMP INSTALLATION D tl f SYSTEM REPAIR ❑ L OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTUNE'WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation. + F ,, — Dia. of Well Casing © Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ! Specifications ❑ Public ❑ Other ❑ Dell Depth of Grout Seal 1 ❑ Irrigation _�q F Type of Grout ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _I H.P. State Work Done Well Destruction ❑. Wel! Diameter ` ,. F .,.Sealing Material itopr50'M Depth Filler Material 1Below 50'1- TYPE-OF SEPTIC WORK: NEW INSTALIXTIOWO REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is ' available within 200 feet.) l Installation will"serve Residence-- Camercial Cither F i Numd ber of living,un,its--.. �" J#N mber ofbedrooms Character of soilepth of 3 feet: _ t — . " J Water table depth SEPTIC(;