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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781 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 permit 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 <br /> and the Rules and Regulations of the San oa/quin Local Health District. <br /> Job Address t G� Q Subdivision Name <br /> Phone <br /> Address t a <br /> Owner's Name f Phone <br /> Contractor's Name CiC-'ll- License No. <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [] DESTRUCTION CJ <br /> PUMP INSTALLATION [] SYSTEM REPAIR <br /> OTHER EJ <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 AREA CONSTRUCTION SPECIFICATIONS. *1-1 " <br /> Industrial [f Open Bottom []Manteca Dia. of Well Excavation <br /> Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public F_1 Qther []Delta Type of Casing <br /> F—IIrrigation Approx. [ Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> 17 Geophysical Type of Grout <br /> Other Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION X (No septic tank or seepage pit permitted if public sewer is <br /> _.�. ,�,,,e�rr ` available within 200 feet.) <br /> Installation will serve: Residence � Commercial _ Other G�r�% <br />