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I <br /> fi APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'Y£AR 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 described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welltpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ! r C &n, <br /> Job Address ,� f 6 (o +� � f fr A1 I7 City Lot Size PM <br /> Owner's Name Ma Address _14M OVE- Phone <br /> Contractor IV 5i_l`=ZZ5 S,/ License No.! 7? Phone <br /> TYPE OF WELL UM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ['� f SYSTEM REPAIR ❑ OTHER_ ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ----ter �FOUNDAT4ON-i ---: -`-AGR1CUL-TURE W.ELLa— - - OT-HER:W.ELL r PETS/SUMPS -- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open,Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> Domestic/Private °❑fGravel Pack —4r4l❑`Tracy—_-'—Typi:-6f-Casing= Specifications <br /> it Public f 1 Other F1 Delta Depth of Grout Seal Type of Grout \\�� <br /> k I I Irrigation _.-Approx. Depth i I Eastern Surface Seal Installed by _ <br /> r Repair Work Done ❑ Type of Pump SCd f H.P. j 3 State Work Done -u <br /> Well Destruction ❑ Well'Diameter Sealing Material (top 50') <br /> Depth — Filler Material iBelow 50'1 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.I�RCPAIR/ADDITION LI DESTRUCTION I I (No septic syste&`Wrrmindd if public sewer is- <br /> } available withirf200 feet.) <br /> LF. <br />