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APPLICATION FOR PERMIT '!F <br /> if E - I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 4 <br /> I� 1601 E. HAZEL 1 ON AVE., STOCKT ON, CA i <br /> Telephone (209) 466-6781 I <br /> PERMIT EXPIRES TYEAR'FROM DATE ISSUED' <br /> (Complete in Triplicate)w <br /> r it t o tru { - <br />} <br /> Application is hereby made to tFie San Joaquin Local Health District for a permit to construct and/or install the work herein describe This application is <br /> �` <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Ryles and Regulations ofhe San Joaquin <br /> y� ,}tar t5j r - <br /> "Local Health District. WIE <br /> - <br /> y , City' yLot SIze PM ' <br /> .lob Address � <br /> # _� a <br /> �b;x t' Edi <br /> ddress - - <br /> Phone <br /> Owner's Name' <br /> License No Phone <br /> E <br /> Contractor Address <br /> TYPE OF WELL/PUMP: I�' NEW WELL ❑ WEL`REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION* SYSTEM REPAIR ❑ OTHER Q <br /> LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UM <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM-AREA fCONST-RUCTIONxSP,ECIFICATIONS Dia. of Well Casing <br /> Cl Industrial ❑ Open Bottom ❑ MantecaDla. of Wel! Excavation <br /> ,- T a of Casing Specifications <br /> Domestic/ rivate [3G ravel Pack ❑ Tracy yp Type of Grout <br /> r ❑ Public . E3-Other [J Delta Depth of Grout Seal <br /> L1lrri ation. � �pprox. Dept Eastern `Surface Seal Installed by <br /> Repair Work.Done EJType of Pump <br /> H p State or ne <br /> Well Destr ction Q Weil Diameter Sealing Material (top 50'l <br /> 4"+ De�ith Filler Material (Below 50'1 <br /> P <br /> ( TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ avlailabllelwi within 200 feetc system .) i# public sewer is <br /> s �Ir <br /> Installation_wi11 serve: Residence_ Commercial_ Other <br /> Number of,living units: $1 Number of bedrooms <br /> Water table depth <br /> i Charactero soil to a deptFi of 3 feet: <br /> { Capacity No: Compartments w <br /> SEPTIC TANK Q TypelbAfg , : _. <br /> �, , � Method of.Disposal r <br /> f PKG:TRFA-TMENT PLT. El "' % ; # <br /> 4 Distance to nearest: Well Foundation Property Line <br /> ; . <br /> Zo <br /> %ITotal length/size <br /> LEACHING LINE C ' ❑ ;I Ndr-&-L•ength of lines1 <br /> S' ql _h..� ; <br />