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�-�2t <br /> �p <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> 1601 E. HAZEL70N AVE., STOCKTON, CA RECEIVED <br /> Teleptlorie (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JAN 12 1990 <br /> I Compluw in Tripfica�,,j SAN JOAQUIN C(M.-ITY <br /> P11 <br /> Ailptic,tfiun is h0feby made To the San Joac;-in Local Heath Dwiict for a p 00VISION <br /> ph <br /> cation is <br /> M, PF�!" <br /> Local Hualth D,Illjct. -Wil!or:,uwjuu ur Nlu.i -0-41 Re <br /> l"ad"'COmPt'drIcu with Sall Jujquin County Ord1f]-cu Uu SwIlowum9p. <br /> -.,P—of o San Joaquin <br /> �X—sp, <br /> Job Addrobs 7 4 9 E <br /> S-11a—rteE-99-y- City- -tQCkf--Q1L- Lot Sije I i7X12-1--EtPM-- <br /> Owner's Name Gasrn QjI Co <br /> Phone Sq7-0271 <br /> ,,-tAa,,,, 2741 Rivt�r Rd . Modes;�'9.....,4461570 1)537 <br /> �01 - 767 <br /> 1 frt Ul-WLLL/IIUMP: NEW WELL' Phone S_209)537 <br /> WELL REPLACE NT li UESFA—UCTIONLI <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER 6r /r, <br /> DIS'kANCE TO NEAREST: SEPTIC TANK SEWER LINES -- DISPOSAL fLC,_ PROP. LlUE <br /> -4 FOUNDATION AGRICULTURE WELL -- OTHER WELL%0.rg­t_ PiTSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial <br /> -00mestic/Privale I-'I Gravid Pick as no <br /> d open Boll-m '""e' 5�4-of W;11 Excavd til---L D a.of W I C i <br /> J':PLJI)Iic (2 Other I-J Tracy Type of Cabing'',Evc, SCII 4A-- Specoicattons <br /> 111puallat) Sand (I Delta Dell"101Gfoul Seal 3-5-L-APX1LY-- TypuOfG(ou[N.Q_at_r6M0n <br /> MIMI I J Easlu.,n <br /> Repair Work Done 0 Typo of Pump SIAlfacu Seal Inbcd1juLl by <br /> Well Destruction El Well D'amulef H-P- State Work Done <br /> Depth SOdling Material(lop 50,) <br /> Filler mateiial(Bolow 50,1 <br /> 7y;--Mf ZLVIR;wonl<; NEW INSTALJ-A1JON f: RIPAIRIAODITIO L.1mi6litili I I INo <br /> selltic hy%lol"Deffilill.el if pillille sewer is <br /> Ins"latiOn will serve.- Residence aviijab:0 within 200 Joel.) <br /> -I r" Commu(cial— Other <br /> Nunber of living unow— Number ol bedrooms <br /> Chatac;101 Of soil to a depth of 3 feel: <br /> i SEPTIC TANK 0 Type/Mfg Water fabfo depth <br /> cal)activ--- No.Companments <br /> PKG.TREATMENT PLT,0 <br /> Dis.-ance 10 nearLst.- Well Foundation Melhod of Dispasal <br /> PIOPglily Line <br /> LEACHING LINE Ll NO-&Length of lines <br /> Woll Total iongth/size_ <br /> FILTEFI BED El Distance 10 nearest: Ou lcldl4an_ Property Line <br /> SEEPAGE PITS r I Dopill —Siz Numbof <br /> sumps 1.1 Dizaance to nearest: Weeull <br /> DISPOSAL PONDS C1 Foun alion_ Pfopurly Line__ <br /> I hereby certify chat t hawe Ff6PdFod this dpplication and that 1110 work w0l be clone in accordance wi,h Sinjoaquin county ordinances,stag <br /> rules and regulations of the San Joaquin Local Health DiMricl. 0 laws,and <br /> Home owner or licensed allent's sil)nalufO certifies the following:1 certify that in the performance of the work lot wh,'ch this porgg�l is issued.I shallilot <br /> 111111310V any person in such mannor as to become subject 10 workman's compuns;AfiDn laws Of Caid0filid.-Controrlar's)licing or sub-cOntlacting signature <br /> canifies the following;"I conify that in the Performance of the work tat wh�cfi this permit is ibstiud,I shall G(TIPIOY paisons subject to workman's compensa- <br /> tion laws of C lifoinjil." <br /> Tile uPfificant amuv It f 11 <br /> X::��1,1 8 ncqu, -P. I!ons.Complete drawing on lovurse bide. <br /> Signed Title; Cw n Date, <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Dale—40-1-IL- Area <br /> Pit Of Grout Inspection by Date Final Inspection by <br /> Adclilional Cognnglmj� Data <br /> �11EPART�MEIJT US�EO'Nl- <br /> 0 S:k 466-67SI 0 Lodi 369.3621 0 Maniacs 823-7104 LJ Tracy 835-6395 <br /> Applicant-Return all copies to:Environmental Health Permit/Services 1601 E, Hazollon Ave., P.O. Box 2009, Sik,,CA Mal <br /> FEE AM01UNT DUE AF-40UNT REMITrED <br /> INFO q <br /> 'IL-ASil RECEIVED JJY DATE PERMIT'NO. <br /> CH 1'24 IREV."01 <br /> 11114 <br />