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APPLICATION FOR PERMIT �rA F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT G <br /> I 1601 E. i,HAZEL T ON AVE .,�STOCKTON, CA <br /> i Telephone (209) 466 6781 RsccVEE) <br /> PERMIT,EXP;IRES 1'YEAR FROM DATE ISSUED; 0 CT <br /> 4 8 ;,Zi, <br /> IComplete in-Triplicate) IAN JOA <br /> p �:rfV CO!� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or� iit',Y��o�k'�r�ey"��t� +�, YThis application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage o'r No.`1862 for welllpunO M UCl d eg�r i f�4he San Joaquin <br /> I Health District. I` i H�Isf�?I`•, <br /> Loco a <br /> fi ' is <br /> �Z'f 6 (51%s '� rr�ON4 a �y <br /> iC <br /> Job Address � � City *%C -+dM Lot'Size PM i l <br /> Owner's Name C liev r4 M ., USA. Address Z �� Ca f r0 Ramolin Phone At k57-89 - <br /> Contractor D Address 7osa. Alte- License Nt. N '343 Phone "�7 <br /> TYPE OF WELL/PUMP: G NEW WELL =` <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ ; <br /> PUMP INSTALLATION ❑ i `' SYSTEM REPAIR ❑ OTHER X Soo E6&-irr4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES k DISPOSAL FLO. PROP. LINE 1 <br /> FOUNDATION AGRICULTURE WELL ' OTHER WELL I PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca 1j Dia. of Well Excavation Dia. of Well Casing <br /> wla <br /> ❑ Domestic/Private ❑ Grav yl Pack ❑ Tracy l Type of Casing a Specifications �} F , <br /> f'] Public F] Other Delta Depth: <br />