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l , <br /> APPLICATION,FOR PERMIT <br /> SAN JOAO,UIN;LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> p . Telephone {2091 466-67$1. <br /> PERMIT EXPIRES 1,YEAR'FROM DATE ISSUED„- <br /> It �­, (Cornplete•in Triplicate)',,,-f, •T <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 /> Lorca) Health District..,,,-w."Pie. <br /> CIO 011t �4- <br /> Job Address . . City Lot Size J0 PM I <br /> T:. <br /> Ow/yner's Name Address Phone <br /> _Contractor's Name i ense No. �P •_ Phone <br /> TYPE OF WELL/PUMP:' NEW WELL ❑ WELL REPLACEM T ❑;+;.ris DESTRUCTION ❑ <br /> ! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑€� OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES biSPOSAL FLD. PROP. LINE <br /> I�. FOUNDATION AGRICULTURE WELL*,d 111'�`&HER WELL PITS/SUMPS p0 <br /> i INTENDED USE TYPE OFtiWELL PROBLEM AREA CONSTRUCTION;SPECIFICATIONS <br /> ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Vllell+Casing -- F <br /> ❑ Domestic/Private ❑ Gravel Packs `'+ ❑ Tracy ti Type of Casing } Specifications <br /> ❑ Public ❑ Other i= ❑ Delta �' '; Depth of.Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth` ❑{Eastern ' 1 Surface Seal Installed by <br /> Repair Work Done ` ❑ Type of'Pump .F Ao `H.P. a _ !� State Work Done Q <br /> Well Destruction ❑ Well Diameter �Sealing'.Material-ltop 50' 1�� Q <br /> Depth .a Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑11 , REPAIR/ADDITIO DESTRUCTION G (No septic system permitted if public sewer is <br /> : t 1 - t"1, available within 200 feet.} <br /> [Installation will serve: k Residence Commercial._ Other <br /> Numbfer of living units: Number of bedroom0_Ld <br /> _�_. <br /> Character of'soll to a depth of 3 feet:' A l s Water table depth £ <br /> SEPTIC TANK Type/Mfg �tt 4 Capacity L No"Compartments + <br /> PKG. TREATMENT PLT:❑ x Method of bisposal <br /> 7 Distance to nearest: Well Foundation "° - Property Line <br /> LEACHING LINE ' No. & Length of lines k Total length/size "-` <br /> ` F[TER`BED ❑ .Distance to nearest: 'Well .' Foundation CIO Property Line i <br /> SEEPAGE PITS Depth Size' Number <br /> SUMPS - �•❑`'"Distance to nearest:"'-Well ` " Foundation Property Line - <br /> DISPOSAL_PONDS. ._ ❑ - _ t <br /> hereby certify that I have prepared this'application-and-thaf'the woik'.: <br />