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APPLICATION FOR PERMIT <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> - !601 E. HAZELTON AVE., STOCKTON, CA ., <br /> Telephone f204I 466-6781P <br /> .d <br /> PERMIT EXPIRES 1 VEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Tlds appacation b <br /> App <br /> Tado on co 191MIee Maden the Sin County <br /> LOG{!H9 NO 5491 101!w 8 p 0' o'1862 for and/or Ir and the work hwainWAR 141 1%Of the San Joaquin <br /> made in tomyliance with San Joaquin County Ordimnci No.543 for sewage or No.1862!er wNl/pumr and tM Rrdc aM Rego ., <br /> +: Lnul Health Outrin. '61-V 6 /�. V <br /> Job Address �L— t-'— ""5� PM <br /> C _ <br /> Owner's Nama Address / PQM �/ y <br /> 9r aA fa9.t .moi - _ �l UT <br /> Llcenxo No.� Phow <br /> "--C�ntractw <br /> F TYPE OF WLLL'PUh1 . . : NEW WELL ❑ � WELL REPLACEMENT i7 UEfiTRUCTION O, <br /> ;PUMP INSTALLATION ❑ SYSTEM REPAIR ,7 OTHER 0 <br /> ` - - f DISPOSAL FLO.__ PROP LINE - <br /> . ;c - DISTANCE TO NEAREST:'SEPTIC TANK --SEWER _(NES _ pITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL __ OTHER WELL _ - <br /> :NTENOED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Da.of Well Casing 'r <br /> 0 Industrkl U Open Boftpm 0 Man!ecs Dia.of Well Excavation .Specifications <br /> F•- 0 Dan kipifves �0 Gravel Psck '� 0 TiI . Typo e. Casing <br /> -' .. _ 0 Delta Depth of Gout Seal _. . . Type of Grout <br /> I^ Pudic .1101. .. <br /> I I Eeatem Surras•Seal Installed by ' <br /> I ItrtigatkNt —Approx. Depth .xi <br /> RI Wolk Donn. 0 �TYPa of Pump A.P. — Slate Wwk Dohs ^ <br /> i� Well Destruction 0. Wag Ciametw ISeafirrg Material Ity. 50'1 . . .. <br /> - - - th -:Filler Material I slow 509 <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION I.I a REPAIR/ADOITION DESTRUCTION 1 1 INo septic synem I1el11etled if puI Sewer n <br /> available within 700 fest.) <br /> p i <br /> 1- -- <br /> Installation.0 serve. P n Jntce...�. t.orr!morcfel Other <br /> " Number of riving units: Momper of tredroylp n`rs�GZ_ - f <br /> XXWater table depth <br /> 4 <br /> -Crau ac.ar M sod to a depth of 3 fee.: <br /> .''SEPTIC'TANK•..' 'C)`Type/M.fO ._Capacity— <br /> SEPTIC - No.Cornpwumvo <br /> . Method of Disposal <br /> PKG.TREATMENT FIL .O '" .._.-- . . _. .. .. - <br /> . ... a <br /> D'atance to norm: ..Wev_-- Fouindation _ Property Line , �r N <br /> __ <br /> � f <br /> FJACHING 0 No.9 Longlh of fires -Tctr>t imgth/si:e <br /> EED I"J Dbtarl-e to nba"I: Foundation _ Property Lkre a <br /> SEEPAGE PIPo I:I f�aLh d 'e.�_ - Ntr�MM L <br /> SUMPS0' Desk to neatest: Well. �6 _ Foundations property LvRr .. <br /> �DISPO,+AL"ONUS L' Cllr -. .,. _ .. <br /> I hwweoy rotary that 1 hens Frthis application and that the work wfiR be done <br /> In zccordanro with San Joaeuin rxruNY ordfrMntm,.aen Iowa, erw <br /> ries and.regulaut"of the San Joaquin Lazar Health District. ;I Thst in the peAwmenro of the work for lNltkJt Oris pgromit is Wond,l s1tY not - <br /> Horrw%mar m gconsed agents <br /> Signature can;iea Ma.fo0cw+rrrk".L'enRy non(ewe of Ca5lomis.•'.Contractor's hkktg or wbeormaewu slgtMlure <br /> . ar,Oiy env parson in each rrraI as to became subject to workman's corzMrfaa� ���s ror'+Owre+- `. <br /> xdR jh I;pf xr1rrg;,1,*e tY,that yr tM per•. of mo work for whkn this permit Is issued.I sfetl employ pdrmrre eubjact <br /> tion <br /> Thea rnapoet to r rove <br /> . Fra(/ d 2 Data: - r <br /> spared%=— .— .. <br /> _ :�.. <br /> . FOR DEPARTMEIL'T USE ONLY .;8 <br /> Dat. 1 O <br /> �A.pplicstlwr:,c aC!ed OIr C Mi o �� I <br /> Oita—- Finallntpeu'Eon by Date <br /> Pt w Grvt Inspactlon by! _ <br /> A <br /> -� pdwonal f:Om4&1781 frenu I • - - X <br /> y� - O Wdi 3B9.3(f21 ❑Msntata SM-7104 ❑Tracy 6fT.53ly <br /> ppcam- Fes",­sA copier.W:Environmental Heahh Pafmii/Scrvius 1®1 E. Hazelton Ave.. P.O. Bos 7J03,S1k.,CA 115101 <br /> RECEIVED 6Y M'+E .. PERMIT'NO. <br /> { INTO AMOUNT OVE AMOUNT REMITTED CASK /�,L'/ry• <br /> t)t 2N e1N:•,,e,rl - ; � �'// C��r.� � / I " /- �33 . <br /> r � <br /> A <br /> s� <br /> 5h <br /> Y <br /> x._n <br />