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APPLICATION FOR PERMIT <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> i Telephone (209) 466-6781 <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 described. This application is <br /> F 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. 36 <br /> �-�• <br /> a Job Address V city " Lot Size PM <br /> Owner's Name edluise Lopea ,�sAddress /[ �—� <br /> Phone <br /> ContractorU � Address C cJ i1/VI License No. Id Phone A/sz✓b <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WEL�li'M-EfVARtA CON-STRMTRM SpECTFIU ,�fl <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationt <br /> Dia. of Well Cas. <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac g <br /> Y Type of Casing_ <br /> If f <br /> g Spec.hcattons ^{^ <br /> M Public ❑ Other C7 Delta Depth of Grout Seal ` (� <br /> I I Irrigation _ A Type of Grout Q <br /> Approx. Depth I I Eastern /uriace Seal Installed by <br /> Repair Work Done ❑ Type of Pump k � WP. State Work Done <br /> Well Destruction ❑ Wel! Diameter Sealing Material (top 50') ._I.1 filled <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 AEPAIR-/A-DOITION 13 DESTRUCTION I 1 {No sepTiC-system pormitti d it public sewer is <br /> avrailable with 200 feet.0 <br /> Commercial <br /> Installation will serve: Residence -- ;0ther I f <br /> Number of living units: Number of bedrooms �� i <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK --- ._.__ Water table depth I <br /> ❑ Type/Mfg s Capacity r No. Compartments i <br />