Laserfiche WebLink
APPLI� TION FOR PERMIT <br /> SAN JOAaUI .LOCAL HEALTH DISTRICT <br /> MAR <br /> 1601 E. HAZEuTON AVE., STOCKTON, CA <br /> NVIR�3Mrr +'l�ltr kll=ACTHetephone,.(209} 466b781 <br /> PERtolf/SERVICES iPERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> C. 3 1x �' .°"3 l+ri& •;�,'��rt v <br /> C. �,�i h 1��� kl�arnplete'in Tripl'iaete}. <br /> ! - 1 } <br /> Application is hereby made to the San Joaquin ,��Hes District for a permit to construct and/or insmll the-work fiereha described.,l epplicatiort is: <br /> s. •. ,:• ! <br /> =maw in'.00mplfeinoevvidif batt.loequirrCwtrn:>14rditiant +fo:X49 for sewage or No 1862 for well/pump and the R Aes ainil Repulatlbrtsf thie'5an`Jdiquin'+ <br /> Local Health District!,") <br /> .lob Address 5. "�r T[ &0 LoVS+ze 'IPM <br /> Owner's Name Address Phone <br /> 77 <br /> a__ <br /> Contractor Address -! Rte- License No: �� Phone 1,6 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION :❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST, SEPTIC TANK- SEWER,LINES DISPOSAL FLD. PROP. UNE <br /> FOUNDATION ULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PRO EA . CONSTRUCTION SPECIFICATIONS, <br /> ❑ Industrial ❑ Open Bottom ❑ int" Dia:of Wdll-Excavation Dia, of Well Castng'• <br /> ❑ Domestic/Private ❑ Gravel Pack C3 Tr�cs7" Type of Casing Specificattoria <br /> ❑ Public 0 Other 13 Delta <br /> Depth'of Grout Seale.• Type of Grout <br /> ❑ 149ation __4ppiox. Depth ❑ Easter ' Surface Seal-Installed by <br /> Repair Work Done El Type of Pump.1 }H: <br />