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` FILE <br /> i <br /> SOPYE. <br /> APPLICATION FOR PERMIT } <br /> h� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s 1601 E. HAZELTON AVE., STOCKTON, CA ' <br /> 3 Telephone (209)468.8781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) n. <br /> a Application it hereby made to the San Joaquin Loco!Health Dtet►kt for a perrrdt to tonatruel a++dlex ktstsll 1118 yep,Ow!*it .T14s applikaftim is <br /> mach in compliance with San Joaquin County Ordinance No.619 for-- V-ONO.18162 far wrNIPWV and lits Ruler•std Regalaiimm of&*San jummalm <br /> 3 Local Heellh District. <br /> i Job Address 3 1 f?F <br /> `-{ pn �•{� ,, _ _i'11, /�I `tCkY Lal$iw plYl <br /> Owner's Name'"�---._. '__�J_J� m� Address <br /> phow <br /> Con Ira cAL';;41��C�*+..I�L{i AQdress � �` J License No. Q��Pholte 3F_ oslQ•• <br /> t <br /> TYPE OF WELL/PUMP: NEW WELL I: WELL REPLACEMENT CI 0E$111UCTIM U <br /> PUMP INSTALLATION ❑ / r <br /> $T$IIA REPAIR Q bTMYtI O <br /> DISTANCE TO NEAREST: SEPTIC TANK . SSR LINES — .._.._ DISPOSAL FLO. PROP.LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS_ r icy <br /> _ q. <br /> INTENDED USE TYPE OF WELL PROHLEMAREA CONSTRUCTION SPECIFICATUM <br /> rn Industrial Cl Open Bottom 0 Manteca Dlr,of WN ExeawNon -- Dir woo rM Catling <br /> Oontestie/Prismata f1 Gravel Pact 0 `.ecy Type e! $Pa�f worts „k <br /> ` 'ublic f 7 other n Dana DO",of thea)Seal TV"d flfoul "n <br /> ltrigrtian <br /> ---Approx. Depth Ij Easter SWIM*Sate 11tr "by <br /> Repair Westin Done El Type of Pump H.P, $Isla Wlrrlt Oens <br /> War Destruction Cl Well Diameter Sealing Mats"glop!IO') <br /> Depth fitter IMalerial(aw f>b'f _. N <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L+111EPAIR/ADDITION tiDESTRUCTION 1 ? <br /> I ��R fxlbMe sewer is T ' <br /> frtR.l r <br /> InstaUWA WM serve: Residence_� Conrnerekl— Other a <br /> Norham of iivWg t.nim Number of be oma f `r <br /> Char=w of soil to a depth of 3 feet. <br /> C5PT1C TANK I i Type/Mfg 1 .42ag lip.�b <br /> PKC.TREATMENT PLT.Ll <br /> r Mallwd of <br /> Distance to to nearest: woo .SO Foodetion, Proprlty Ll,y <br /> LEACHING LINE Itt"'No.8 Length o1 tines TOM bnow <br /> dleF <br /> fILTER SED CI Distort*to nearest: We0 �� Foundation _ Papp9rN Llfta ��. <br /> 4 � <br /> SEEPAGE PITS [It-Depth _19S ,,_SU* <br /> SUMPS (] Distant*to neatest: WaliLQQ�-. Foundation . LQ_.._•ft*"Lina <br /> DISPOSAL PONDS I:! <br /> I t+eratftr t:eRlfy That 1 have prepared this apt icatien and that tine work wW be dura In aeootdarloa with San JesgWn wtwy ordMtMneas serfs team and <br /> ndn and NVAtions of the San Joaquin Local Health District. µ <br /> Home owner of Hcaneed agent's signature certifies the foR.twkms:•11 tertiflr that to she pErforntanea of the work for it 1)fila prtnrrit is wwav A,a a"nee <br /> atr00 any pemon in such m,.nner as to became subject to workman's eoryVensation%m of Californw.'•Corer= is hkirgs atAtaonbaeriq trlatseurs J <br /> oartiflss tura fonowinp:"I certify that in the performance of the work for VA alfa permit k leaned.1 tdrll srrtpary prtrasrra subject td warrw►s eorrrparnas ,„ <br /> tion laws of California." T <br /> The applicent can for u.f rasPKtions.Cextq+tate do v q an twerea side. r� <br /> Tick: Daly; <br /> FOR DEPARTMEW USE ONLY <br /> AXACCUM Atxepted by ' �?rae <br /> �i or Gtout fnapectktr by -5� Date��Finsl ingeeetkn by �y Dane f ' <br /> Additional Comments: frc x <br /> 0 SIA 4W081 0 Lodi 3S9-3621 0 Manteca .923-7104 ❑Tncv 81T4= <br /> Appkwwt-Return all copies to: Environmental Heetth Permit/Servkes loot E. Hasatm Ave.,P.O.4ou 3009,Stk.,CA MM <br /> . a <br /> FEE AMOUNT DUE AMOUNT REMITTED CASrf AEcam By DATE IEaRI't'no. <br /> IHT O <br /> EN NNa <br /> t7—/—,P7 — <br />