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Jun 16 05 08: 15a San Joaquin County 2094689907 p. 3 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091466.8781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is laraby mads to the San Joagwn Local Health District 1hr s pemilt to construct and/or knaat chs work heroin damaltW.This alwhcodon Is <br /> rrrade in tamp68rras with Sen Joaquin County ordnance No.50 for sewage or No.1942 for well/pump and chs Aube an0 Rpulations et the San Joaquin <br /> LOW Health District, <br /> Jab Address �ra a�l9 /�.t/�LIEr �Or41a City•Stitt/ Lot Size AM)[4114 O PM <br /> Owntrr s NamoB-11 udGY+ Address 2319 Z 0M daft Phoma <br /> Cptlracttx l'RBQDS� �� � Address O Ucense No.aAj%3 Phone <br /> TYPE OF WELUPUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION O <br /> -� PUMP INSTALIATION O SYSTEM REPAIR O OTHER ❑ <br /> TANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE l <br /> '� 1 FOUNDATION AGRICULTURE WELL OTHER WETLL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O IrdmtaW O Open Bottom 0 Manteca M.of Well Excavation Om.of Well Casing <br /> O Domer* c/Privam 0 Gravel Pack 0 Tracy Type of C—inn Specifications <br /> :i. O Public 0 Other 0 Delta Depth of Grout SW Type of f3nout <br /> 0 Irkpsio r ___APPox.Depth O Eiimrn Surface Seel Installed by <br /> Repair Work Done ❑ Type of Pump H.P. Stats Waft Dons <br /> Wall Daserocwty 0 Wet Diwneter Seafirp MsWW flop 501 <br /> Depth - - - Filler Material(Below 5(') <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTMON No asplic Wxbwn farnatad if pubo sewor in <br /> available within 200 fest.) <br /> Installation wN serve: Residence01, Conirne cial Other <br /> Number of king waifs:A- Number of bedroom <br /> Chwacter of soil to a depth o(3 few: OWILF- /ems .. Wer table dsplh <br /> SWTIC TANK ■ Type/W9 rCrpe6sy tYle3e7':. N0.Cpmyfaranents <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> Oisiance to nearest: Wall A' Foundation Property L41 :4,21 1 <br /> S <br /> l <br /> LEACHM LINE 0 No.&Length of fines 3 X 90 Total laffiflthjal� 70 <br /> FILT018ED 0 Distance w newest Well Foundation Propaity Line <br /> SAGE PITS 0 Depth Sine Nwribsr <br /> SUMPS ❑ Distance to newest: Wet Foundation Property Lints <br /> DISPOSAL PONDS 0 <br /> l hereby artily that 1 have propend this applications and that the work wU los done in accordance with Sot Joaquin country ordinances.edeas laws,and <br /> rales and moubdora of(fie San Joaquin Local Health District. <br /> Moine owner or teased agenCs 2WOU"CeMTtes the following:'h certify Ilia in the perforansnce of the work for which tills pairnit is 4sued,l slwN trot <br /> overplay ell P*wn in suds manner as to became subieet in warkman's compensation Dews of California."Contractors haft or rub-contraclmg eipiMill" <br /> cnuCna the f*w#A :-1 ratify that in the Performance of the work for warmth chis paerWt is inued,I da employ parsons sublect to workman•:comparses- <br /> dw mea of California." <br /> The appT _must eat for all required Wspections.Complete drawing on reverse ride. <br /> Biomed Title-A Date: -ns-e� -- <br /> : FOR DEA USE ONLY <br /> Apptortioe Aeeepmd by / Iota <br /> Pit or Grout Inspection by �- Oats Firwl Itepscti0n by Dana Q <br /> Additional COrrinants: � <br /> ❑fi;tk 4WP6 1 0 Lodi 368 awl O Mm"M M7104 0 Tracy 0354M <br /> Appi=M-Retum at copies to:6dNronraarng Hsft Permit/Servicea.1001 E.Hawltoo Ave.,P.O.Bos 2008,Stk.,CA y67rp1 <br /> Fe AMOUNT DUE AMOUNT REMITTED SH RECE/W 6Y DATE PON-r-No. <br /> .fl1.197a atEV_riesd <br /> IN"a `?'Q • : _. ��1.V <br /> b0/T0'd 6556£bS60c NOS'13WZS-100d bZ:LO 5002-9T-Nflf <br />