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f APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 46&6781.., .9 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicatesoaquin ifs <br /> t and/or <br /> .This <br /> is <br /> Application is herebyM ode to the <br /> Joaquin County Ordinalnce No:District Health 549 for sewage or No. 1862 for cwell/pump install <br /> nd the'Rules and Regulations of the San Joaquin <br /> n <br /> made in compliance <br /> Local Health District. <br /> City Lot Size - ! PM <br /> Job Address <br /> / L+/�.� r I /Irl <br /> JQ1 e - �i i Address f V - Phone a- _ <br /> Owner's Name <br /> c+�A License No. Phone <br /> I Contractor •mac "r Address <br /> TYPE OF WELL/,PUMP: NEW WELL,❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ OTHER IJ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES _� - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> % <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ <br /> ❑ Manteca Dia. of Well Excavation <br /> Industrial ❑ Open Bottom Specifications <br /> Type of Casing <br /> ❑ Domestic/Private � ❑ Gravel Pack ❑ Tracy Depth of Grout Seal _ Type of Grout <br /> l ❑ Public a:❑,Other ❑ Delta <br /> Ll Irrigationpprox. Depth ❑ Eastern Surface Seal Installed by <br /> of Pum H.P. State Work Done <br /> Repair Work Done El Type p- _ <br /> Well Destruction [_3 well Diameter' Sealing Material (tap 50'1 <br /> Depth ` Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION [IDESTRUCTION ❑ (No sbpti cwithin system emitted if public sewer is <br /> Installation will serve: Residence Commercial ether <br /> Number of living units: Number of bedrooms <br /> Water table depth a� <br /> Character of soil to a depth of 3 feet: j Z No. Compartments a <br /> SEPTIC TANK Type/Mfg - P d �- Capacity- <br /> -Ir� ..) - Method of Disposal <br /> PKG. TREATMENT PLT. D. L4 r / <br /> Distance to nearest: Well! <br />