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i <br /> APPLICATION FOR PERMIT <br /> y '17� ie SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1�, € 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> s 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 /> 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 /> I Local Health District.. <br /> Job Address a.7. i"/�N /�F-¢ City'. ?,-_J!9X2VR Lot Size PM <br />' Owner's Name 10, 4 Address®� 4"//lf�-1�0 Phone AM n w <br /> /�/� 0 <br /> Contractor A -1 <br /> gzw� Address,dwt' _._.".,111A_..._.-_ 25A� License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION <br /> I <br /> i PUMP INSTALLATION D SYSTEM REPAIR El OTHER El <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE k <br /> FOUNDATION_ AGRICULTURE WELL OTHER WELL PITS/SUMPS [ <br /> 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation Dial of Well Casing <br /> i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public -1 Other C5 Delta Depth of Grout Seal Type of out _ <br /> r <br /> 11 Irrigation ' Approx. Depth 1 ) Eastern Surface Seal Installed by er�l t I I L <br /> Repair Work Done ❑ Type of Pump _—_t_- H.P. State Work Done &Zau, <br /> ' l I <br /> Well Destruction )v Well Diameter �� Sealing Material {top 501 i <br /> Depth Filler Material (Below 50 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> �! available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other 1 <br /> Number of living units: IF Number of bedrooms <br /> Character of soil to a depthj <br />