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E <br /> oil <br /> .. <br /> E Cop FIL M <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 486.6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> {� iComplete 1n Triplicate) <br /> ' Appkawn is hereby made to the San Joaquin Lau11 Health Dittrlet for a permit to earutruel mndlW kutaM ft w0 Iw gb daairMltQ,This mOpBaadap 46 ' <br /> made In eomplianee with San Joaquin County Ordinance No.US for wwaoe or No.lM fm well/pwrrp molt!the Raba and i <br /> Y Local Health District, Ihpndffiprts d the San Jbilaw, <br /> a f <br /> Job Address ��`-(``t!C_ <br /> I p lot Sglr PM <br /> COwners Nam�e�-�ftonr_-— '�A Address j(2y II✓ '� , Phery !�7 <br /> ontractaG�Lcro y,,.I �i UG <br /> C c .4�_-Address _• s V� �� ��.Lit Dolma No.�' �PAonei�-r <br /> TYPE OF W#LL/PUMP: NEW WELL I; WELL REPLACEMENT Ll DESTRUCTION Ct <br /> Ali PUMP INSTALLATION 0 <br /> "ISTEM REPAIR © OTN� 13DISTANCE TO NEAREST: SEPTIC TANK _ , SEWER LINES <br /> ;�i - _-� FOUNDATION --~-'--�--- DMPOSAL FLD, PROP. LIN# a <br /> . AGRICULTURE WELL - OTHER WELL_ PITSI MPS _. r; <br /> INTEN_ p E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEWICATIONS <br /> n't Itldtrsfrtsl C1 Open Ban" 0 Mantecm Dia.01 YYi14 Efterallon Dia d WhI1 CallNlp _.. <br /> - ...�. <br /> OomMatk/Private 1-1 Gravel Pack 0 ".dev Type of SPOCNIoalkslM <br /> [I Other <br /> I"1 Dsha Oafsth of Orout SalM <br /> Eas <br /> i <br /> --A - <br /> Irripslion TV"of Or01911111111019111111114 <br /> pprox. Depth C] tern 8trrfaa Saaf lafaMsd by <'F' <br /> WRepair WCAk Oone CI Type of Pump H.P. $Lala Wtult Oona <br /> all Deatructfen ❑ Well Diameter Sawn;Mmlww ttoo 50'1 <br /> Depth fM w MaNeW Ig In. 50'1 <br /> TYPE 4F SEPTIC WOR!(: NEW INSTALLATION L*-REPAIR/AODITION l7 DESTRgJCTgNLl <br /> IN* <br /> 9bNl� °S 1prblie now IS <br /> Initallmtfori wMi neve: Residence_ Commercial Other �l tbt.l <br /> Number of Wing units: Number of <br /> ChMaCler of soil to a depth of 3 feet. <br /> C£PTIC TANK 171 T wmw tabs a <br /> g 'Cr"� ..J1iLsl.SL�. <br /> PIKED.TREATMENT PLT.1-1 < r MMhod of DlRaasl *� <br /> .li Distance to nearest: Well .��0 O_ qty Lke s <br /> LEACHING LINE i't"No. iJ Length of fins <br /> FILTER BED I=1 Distance to nearest: Wog r i� <br /> ploWl Lim <br /> SEEPAGE PITS fit-Depth Sias Nulttbar / <br /> "Ps it Distance to nearest: Wep X00• Flip Q� • �,p y �� A <br /> DISPOSAL PONDS IJ <br /> 1 l!arehy cNtNy that I have prepared this a al tion and that the work wA be darts to <br /> ►apulaCOoedartee with San.Joaquin county ordnartpa �y hiMia.rtd <br /> rules and stkarn of the San Joaquin Local FteNth Otatrkl. ' <br /> HiMill ow w Of kwmd aCent's signature cariifias the foM,twklp:'q cafh that N Lha limformanoe a1 IM work for vMtitfi tftie f»rnrN IS iswred l s(1d not tiF <br /> oa4 010ittti <br /> the parson in such manner as to becn wbject to workman's COMpanaalion Iwra of Ca Iomis."Contraetoes haings wb-conirwtiny al0nnerrne <br /> tion laws of California." <br /> pe+formarlca o}Lha work for whieh this pamVt is iawratl,1 a1+M pq�d <br /> toMOwing:"1 ce that in the *I jp,0lr perw"at,I t0 workmen's <br /> k <br /> Tufa eppMGntUla for at sir insPOCNOM.CcAn*te drw ft on feflerae aids, <br /> S I�: � <br /> - Title: Derr: a� YL <br /> IPARTMEMr <br /> USEOJIfrAp�on Aeixpted bNi � mGrout tntpectkm by DarFin al Inrpsetfon by <br /> AddilionM Comments. <br /> © 4aval ❑ Lodi 3F9-3821 ❑Manteca 823.7104 ❑Tracy 8III41M � <br /> APOiicant Return all;copies to: Environmental Heatth Pettrrlt/Swvion IMI E. Hasshon Ave..P.O.qOn211M Stlt.,CA ALM r ' <br /> FEE i <br /> INID AMOUNT DUE AMOUNT REMITTED CASH RECEIVED sy DATE PERM'NO. <br /> .rM 13-M raw.r^gip. Q d� <br />