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f � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (200) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED w i (Complete in Triplicate) . 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 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 Local Health District. " 17V � Job Address �r^l9dye?� < City'„ %dC.lriGl, Lot Size `71 PIe f�� PM Owner's Nameh 6 Address � O�i� Phone g ~ Contractor Address 14 3L License No. �O TYPE OF WELL/ P: NEW WELL, ❑ WEIL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION`El SYSTEM REPAIR El OTHER DISTANCE TO NEAREST: SEPTIC TANK t1 + t SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL I OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL P_R08LEM AREA CONSTRUCTION SPECIFICATIONS ❑.Industrial �„_,R,�,r ❑ Open Bottom ❑ Manteca \t Dia. of Well.Excavation Dia. of Well Casing E ❑ Domestic/Private ❑ Gravel Pack, El Tracy T c ype of Casing Specifications ❑ Public 4 ❑ Other # ❑ Delta Depth of Grout Seal Type of Grout " ❑'Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump":—",�.'""v H.P. I State Work Done Well Destruction ❑ Well Diameter j Sealing Material (top 501 Depth t. l Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is _...---,-.... t1. ilable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments PKG. TREATMENT PLT. ❑ {{ t Method of Disposal Distance;