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G <br /> APPLICATION FOR PERMIT <br />' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. g 9_ S� <br /> E Telephone (209) 466-6781 ' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED O <br /> (Complete in Triplicate) ' <br /> I_ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations.of the San Joaquin Local Health District. <br /> Job Address /,,._ZIZ _44roeeY _.�", _ Subdivision Name <br /> Owner's Name_ %J''®f b Address i �Ee/� Phone '-.24 ie <br /> Contractor's Name S'cr4rX License No. . �j+ may_ Phone �l[�E�� CIS <br /> TYPE OF WELL/PUMP WORK: NEW WELL Q WELL"REPLACEMENT 1,DESTRUCLIDN <br /> 1 <br /> PUMP INSTALLATION -❑ SYSTEM REPAIR ❑ OTHER ❑ `� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 <br /> FOUNDATION- AGRICULTURE WELL OTHER WELL PITS/SUMPS QU <br /> INTENDED USE TYPE OF WELL PROBLEM_AREA\ CONSTRUCTION SPECIFICATIONS . <br /> 17 Industrial Open Bottom ❑Manteca Dia.-of Well Excavation <br /> U-Domesti-c/P.rtvate. Q..Gravel-Pack-O-Tracy Dia,;»of-Well-Gasi•ng- --* <br /> Publicy. Other Del to a ;� ; w <br /> :. .1. �J.._ ❑ '"b TY <br /> Pe of Casing <br /> ❑ irrigation ` Approx. [] Eastern -%- <br /> Specifications.., <br /> Cathodic Protection Depth a �� <br /> Depth-of-Grout,Sealw-, _ <br /> r Geophysical <br /> .Type.of Grout t <br /> Other ." -F . �' " _"'r a"'"�`., - 3:3. `r°'+� ..l,a..r•�... ,, - <br /> Surface Seal Installed by i <br /> Repair Work Done Q'*Type of Pump H.P. State-Work Done ' <br /> Well Oestructioh, Well Diameter Sealing Material (tap�50') <br /> „�-� x <br /> ` <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK:' NEW-INSTALLATION ❑ REPAIR/ADDITION R (No septic tank or seepage pit permitted if public sewer is o� <br /> available within 200 feet.) <br /> Installation will serve: Residence -Y Commercial _ Others ': 'S A"r <br /> Number of living units: Number of bedrooms Lot size Q0 <br /> Character of soil to a depth of 3 feet: _Si3 Alli Y Water table depth i <br /> SEPTIC TANK ❑ Type/Mfg + Capacity i No. Compartments <br /> PKG, TREATMENT PLT. ❑ Type/Mfg Capacity t Method of Disposal <br /> ' SEWAGE SYSTEM `� �-D'istYFice'^Eo YfE r ?;C j Wel l Foundation 'Property Line i <br /> DESTRUC IONw ❑ t t <br /> LEACHING_LINE No. & Length of lines 7 O Total length/size Y -,-4) _- zz <br /> FILTER BED ❑ Distance to nearest: Well /✓.}v Foundation /G? Property Line-Z�iyo <br /> SEEPAGE PITS Depth Size Number i. <br /> SUMPS ❑ Distance to nearest: Well Foundation €Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance,with`San Joaquin county <br /> ordinances, state laws.;�-and,r-ules= <br />