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<br /> APPLICATION FOR PERMIT v
<br /> t SAN JOAOL11N LDCAL HEALTH DISTRICT /-• Iry
<br /> 1601 E. HAZE',TON AVE., STOCKTON. CA
<br /> i-cler)hone 12091:66-6781
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED6
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<br /> . - {Complete in Tripliralti
<br /> - AAolicanon,s her>f,y mad.•ro the San J<,naur,i,!tcal to ron56•,.ct agdrof,n StalT it rjmk hefPin described.TMs application is
<br /> mane in com'.11Jnce With San.:oaquin County C-rr!nanr.c No.�A9 for s -jqr or P.O. •tY,i?for werDump and the Rules and R?autations of the San Joaquin
<br /> Local ri,fal!h D,s!,i, -
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<br /> I Jot)Address.-„ I w,-1-E 1 ,_.,i•-1 ��11.i t. `,:�_._. .... C:.tv I`-`sr....ii1P.c Lo;Sirc _. -i t,. _.�--
<br /> +.lY, t i _ address �- 1 k�t, tif,•...,- .__..._._ PCon
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<br /> .. Owner s Name ... .�._..�f_L_._-1..._ t�.�..�-,11._.. .-1_�:� 1. r... ' Sti'�.._
<br /> Ctlntratlw's'.dm(+ l:.'_} �.,wL�SiO. 7 Ocer'SeNo. Phone
<br /> w _ - TYPE OF WtLL,?PUnAP: NEW WELL ,, 'NEL REPLACEMENT DESTRUCTION -
<br /> ,r PUr1P tNSTALLAT[CN SYSTEM Rf.pAiP OTHER :_i
<br /> DISTANCE TO NEAREST SEPTIC TANK SEWER L1NF _ MSPOSAL FLL]..—_ _ PROP.LINE
<br /> FOUNDATION _ AG`ICULTUPE WELL -- OTHER WELL_,._.._.T_ P[Tsist)1PS -
<br /> �' VTENDED USE YPE OF WELL PROBLEM AREA CO.'ISTPUCTION S?ECIFIC_A)QNS
<br /> InduSTrial �.~..w_. 'One Dnitnm.. .-M1.AantOc� D.,_ref-Wrh E.ravat�nn _ �.�_..�___ 'Dia.of Well Caging
<br /> Domestic/f eluate Gravel P;ck Tracy Tyne�,l L'amnp _ ..._ .,_,__. Saecificmions \
<br /> Public Gt u;r - _ Dnna - Depth o'C-ow Seat _- _-- _.._-..-._- Type of Grout_--�__
<br /> �,•' L-:Iriig,rtinn _..,..Approx. OeLith - E:rSFem Sur!Ac+`Scal tris;dll--d by
<br /> Repan Work Done 'C; Tyre os Pump ..__...... ..:...... ?+n ._. - S!arc,Werk-Dcae _ -------- --. �l
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<br /> Well Destruction Well Diameter _... $re;,:ung!4late,nai!ion 50 I - .... -- --_-
<br /> 1 Depth
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION •RLPAIti.A[!DIT:ON 0ES1RG1CTtON ik4o sepnc system permitted ii public sewef is
<br /> ,pivailable wrthin 200 frr1.1
<br /> instatfabon will st-n.e. Residence_�( Como crc a :, Other,
<br /> Number of living units: L_ Number of beoroams t. �__, s
<br /> Charac[rt of sol![o a dspth of,]Fcet �.,> %_.� 4't r't�_;+�— ,_I4 } _Water!anis
<br /> SEPTIC TANK TvmtMfn Capacity No.Cxnl,ertmentS
<br /> PK G.TREATMENT PLT.i.' Method of Disposal i `1
<br /> o? - Dista?rw,to nearest.-Y-Well_��.1L� Founda'a /�__-- Property Line
<br /> ;. LEACHING LINE No.8 Length of lines Toral
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<br /> FILTER BED, �D Distance to nearest T:'l7N/�e$ ��. �_Y r�oun6Jaj[ion Property Line
<br /> SEEPAGE PITS Death �.„�'�_Svc .. Nu�.--
<br /> 4 , ..SUMPS _ _ Distance to nares. Well_1Jr,, Fouadabon ,•�.�.P!aperry Line. -
<br /> -b DISPOSAL PONDS
<br /> I hereby certify that I have prepared this application'and that the work will be done in accordance with'SanJoa tole taunry ordinances,state laws,and
<br /> rules and regulations of the San Joaquin Loca!Health District:
<br /> ii 'i ! Il no`
<br /> i h his pe--mii 5 SSUed Stk3
<br /> -. tl - -'F nit that in the _rlormance of the work for which 1
<br /> signature r certifies fo Ow1r' Ce t Pe
<br /> . Horne owner or licensed agent's sgna u e cert es ills g- y p"
<br /> �employ any person in such manner as to become Subject to woikman's ccmpensation laws of California.'-Contractors hiring or sub-convacbrig signawie
<br /> "certifies the following:"I certify that In the tr.rformance of the work for which this perms[is issuers.I shall employ persons suojecr to workman's compensa-
<br /> tion laws of Cafifomia." - - - -
<br /> -The applicant must call)for all required inspections_Complete drawing on reverse side. -
<br /> Talo. Dine.
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<br /> 'FOR DEPARTMENT VSE-CNLY ''''') �'/j '
<br /> A Icetion Accepted by _ X _._...,�_.__.__..__ Date__L r { ' Arca_.��r.
<br /> t 1%�` 57 Final Ins y_
<br /> IV,
<br /> t Inspection by-- Date__� _'-+'- Faction h �OB[eQ -
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<br /> Com rants: _,— _-- --------- --- --
<br /> 0 Sts,.4(16-Ml C7 Lodi 369-3621 C:Manteca M3-7104 C,i Tracy 835 6355 .
<br /> _ Applicant-Re elf copiN to:Erwironmental Health PermIu Services'e7pt E. Hateltnn Ave.,P.U. Box 200r , Sik.,CA�.�Ot a'f�
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<br /> I' - AMOUNT DUE AMOUNT REMITTED 'tA$H RECENED BY DATE PERtAif-NO.
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<br /> set 117a IREV,torkn 1•'�
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