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APPLICATION FOR-PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON-AVE., STOCKTON, CA <br /> Teleph6ne {209) 466-6751 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED w <br /> (Complete in Triplicate) <br /> 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 <br /> 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 <br /> Local Health District. <br /> is <br /> Job Address —I): - City�= Lot Size Cif PM <br /> Owner's NameT-6-w w Coomf Address .� " - _ -"^� ' Phone + <br /> i 1 a4 � c— <br /> ^Contractor's Name LE_T_2' %L�M.JA&LJ"icense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION'❑ SYSTEM REPAIR ❑ OTHER ❑ E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL""PROBLEM RREA CONSTRUCTIOf�SPECIFICATION$;""-"' "'""""-"" '� "` <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing,_ k <br /> ❑ Domestic/Private, ❑ Gravel Pack ❑ Tracy Type of Casing -Specifications <br /> ❑ Public t ❑ Other ❑ Delta Depth of Grout Seal :Type of Grout a <br /> i <br /> ❑ Irrigation X �-s ;r f —Approx.,Depth ❑ Eastern Surface Seal Installed by 4 <br /> Repair Work Done ❑ t Type of Pump H.P. State Work Done ' ' <br /> Well Destruction ❑ ; Well Diameter Sealing Material (top 501 <br /> # r Depth — -. Filler=Material (Below 60') N <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if'public sewer is <br /> I # 1t I� available within 200 feet.) <br /> Installation will serve- Residence_ Commercial Other ' <br /> Number of living units: Number of bedrooms _ .2;j <br /> ` . <br /> Character of soil to a depth of 3 feet:+ '' Com= fir^" -Y # Water'tabie depth <br /> SEPTIC TANK I❑ Type/Mfg F t Capacity` 1. r�No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1, �`=� } Method of Disposal' <br /> f r Distance to nearest: Well l&-)- .Foundation j ! Property Line <br /> l i t `i' t <br /> LEACHING LINE r RL.-No. & Length of lines Total length,/size <br /> FILTER BED ❑ Distance to nearest:. Well FoundationPro' i <br /> ' { party Line <br /> SEEPAGE PITS �Depth -�V Size --..1.f= —fes �NUmber��XR F <br /> SUMPS ❑ .Distance to nearest: Well -#- '� ` I <br /> 11 Foundation Property Line <br /> DISPOSAL PONDS ❑ : <br />