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APPLICATION FOR PERMIT <br /> SAN JOAQUWN LOCAL-.HEALTH'DISTRICT <br /> 1601 E. HAZELTON AVE.,_STOCKTON,CA <br /> Telephone(209)46&4M1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEQ <br /> (Complete in Triplicate) �~ <br /> - Application rs tresebym�m tl,a San Joaquin ter Fleatgt District far a pemrit m eorrstrtat stud/or i,tata!l Atha wont herein descnbed.This appli iS . <br /> made in compliance with Sen Joaquin County Ordumnoe No.519 for sewage or No.1662 for of the S <br /> wall/pump <br /> :-Locai Hearm District. and the Rules and ReB�atim�s an•3oaquin <br /> Jab <br /> - City Lot Site f•. pM . <br /> Owner's Nam ' Addr. <br /> v PhmeNAMWERE <br /> Cattttac Address .a. �� �L'scense N 2 Z Z PtiOne 3��f p <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DFSTRliCT1ON C1 . <br /> PUMP INSTALLATION 0•1,,,4� '�r'•_SYS�TENI REPAIR ❑ OTHER El <br /> TI � <br /> DISTANCE TO NEAREST: SEPTIC TANK __ 5E4VEA LINES i DISPOSAL FL OL PROP.LINE, <br /> FOUNDATION AGRICULTURE 1NELL 4� _OTHER WELL. .PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA - NS)MUgT1ON SPECIFECATIONS <br /> ❑lndusttiar Q Open Bottom O iNantttca Dia-'01,WON.Excavation �. Dia.of Well Casing <br /> Q OpmesticrPtivate Q Gravel Pack L7 Trocy type o -Casin9r.-` -�` .� spectfications <br /> C7 Delta f}P1iG1"x t3 Other Depth of Carout Seat, '� TYpe of Grout <br /> C]Lrdgatian fox.Depthtb¢ <br /> g'❑Eanem �Strtfare 50'1Sea!"lttsia9eA 6Y, fel <br /> Repair Work Done Q Type of Pump I4 p '..•.(s` tsWo`rk DOtre ' <br /> Welt Daslruclim ❑ Was Diameter S.Suog Mammal 4v <br /> , _ <br /> Depth # Filler Ma )al(Below w)r - % '" <br /> TYPE OF SSMC WORK: NEW INSTALLATION Er REPAIRlADDffION,❑ DESTftucnoN CI.(. septic system pwmitted"d pubfc sewer i. a" . <br /> Vj ava,iable within 200 feet.) <br /> Instalimon wan wrva. ReaWwce Commercial.._._-Dn,er <br /> Number of frying ut5fit:/ Number Of �1 <br /> Character at awl to a depth of 3 feat: Water-table depth 3s <br /> - <br /> SEPTIC TANK 0"Typetwo Cawch_! 49 C>.. f <br /> PKG.TREATMENT PLT.❑ I Methodof Disposal <br /> Distanceto neatest: Wall Foundation Property.Line <br /> LFACHING LINE No.B:L*rgfh of fines Tota!"thlsite X <br /> FILTER BED ❑ Distance to neatest: Wellfotitdatiort '' Prapatty Litre <br /> <f ` <br /> SEEPAGE PRS ❑ Depth —size Nund. <br /> SUMPS Oil Distance to news= Wef..._. { F6umiation Property Line • ` <br /> DISPOSAL PONDS ❑ ,{ <br /> 1 hereby certify that I have prepared fhis appfcaliw end that the work will he done in accordance with San Joaquin county Bnfmances,state laws,ands, <br /> rufes and regulations of rtes San Joaquin Local.Health DW l6f�. , gill <br /> Ho, owner OF Iiasswad agem re certifies thpaok wing:'l certify'that in tete performance of the work for which this permit es issued,I=act' <br /> employ-V pats4rr in suet)manner arkta hacartte subleclno vrodm%@n'a aompensation laws of California."Contractors hiring a SubcaMraetitrg signs[vro <br /> fowl laws of�l g „I certH ,�y that in the pwfod 'of the work for which this p.-mit is Issued,i shat employ pef'aotis aulrjery to wgm <br /> ken's.compense- c` <br /> the apPlraam qn call fof���. _dravvvlq cot reverse sf ./�am Tide: JDateFOR DEPARTMENT 113E OMLY 4,yr "•i: - ti <br /> A�pp>a' tdOn.Accepted 6Y Deta <br /> P"e at-AhmA1 Inspection M Date FrrelInpection <br /> by i <br /> Add#k tat Gatanw ta: <br /> Q SIF '466-8781 ❑Lod; 3G93ffi1 ❑Manteca .M7ID4 U Tracy .835-6386 <br /> N*ftm-Return 06 toplas to:&w1rartmantai I IWtI PSI I t/Setviaes fl?011-Hataf en Ave..P.O.Box 21LII9,Stk-,CA MMI <br /> i- tNFd A#AOUMT DUE .AMOUNT HE3NfT7ED ICSH .RECEIVED elfIMT( PaMtrt'Na. <br /> I S <br /> ,7r. ?57 <br /> t <br /> i <br /> i` r <br />