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'-1 <br /> p . APPLICATION FOR PERMIT <br /> SAN JOAQUIN 1OCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 1F)PERMIT EXPIRES 1 YEAR FROM DATE ISSUE �efJ��Q� <br /> (Complete in Triplicate) �" 1 <br /> ApyaKa ,. w(ween marts to Ir.e Sen loaeun local H m Dntncf fa•parrrvt le coneftuct ar!/a MFM dile work gaol 4004/11,64.1;� <br /> made n rom,Aarnce with San JMgv,n C.-t, Orrtaunre No 549 lot sev ape a No. 1867 fw waarpump and the Rule,and RooAli owl of tsliGlln Japlr+r <br /> Local Het1m Onuict C Y <br /> E , _. —q— /, tS Q1Ll��d. CityLot Sin PM <br /> Job Addree _ C ��_ <br /> .fi�L4CE (iT[,' �T+�� <br /> Ownai't Name Adr)ret a _ <br /> .;li Lentratl« _�,,� u. _ Addresf ,L7� Icense N0.27ZQ57/ Plana <br /> 7g7-FW <br /> TYPE OF WELL/PUMP: t NEW WELL WELL REPLACEMENIJU DESTRUCTION O <br /> PUMP INSTALLA�OsJ��J/� SYSTE E'AIR [I PAR ❑ <br /> 019T+vCE TO NEAREST: SEPTIC ! (/ff�[16tER LINES ISPOSAL FLD A'/ PROP LINE <br /> _ FOUNDATION �V _ AGRICULTURE WELL WELL _ PITS/SUMPS _ <br /> INTENDED USE TYtR OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAa.T-I N�9-,-.�� 4 <br /> ❑MCy{�iW- qWp Bonen O Msntw Ds. M WW Eecalls'3 4f moo. lis.01 WM Caoinp <br /> I = (Private Ll Glewl PSU Cl Tracy Type of Curtrg_ Spspficatlons <br /> n Pulsar I Other Il Delta Depth of Grout Stal roe of t�i'Q <br /> Il Imijamon Apmol t�� <br /> Dep . ISI stain SurdKe Seal llalaWd by _I01—Ziar <br /> RepYr Y.urk Done 1.] Tvpa of Pump 's H,H.P. State Work Dents <br /> WallDennreFion fl Well Diameter �. Sealing Meters)(top 50'1 <br /> Dept. filNr Maters) IBb <br /> 92 <br /> ew 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I 1 DESTRUCTION I I INo loom System painted R Wbkc tower n, <br /> avaeabs with.700 feat.) If <br /> Installaton wffl serve: Residence_ Commercial_ Other { <br /> Number of living units: _ Number of bedrooms_ 8 <br /> a Cheracbr of toe to a depth of 3 feet: Water table depth_ <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartmenb <br /> PKG. TREATMENT PLT.❑ Method of Ono" <br /> wDistance to nnerest: Well Foundation_ Property Law_ <br /> LEACHING LINE 1l No. S Length of line _ ToW length/.se N <br /> �t <br /> FILTER BED 1_, nklance to nearest: Well Fwndaton Ropeny line <br /> SEEPAGE PITS I I Depth Sin __._ NIwnSM ; <br /> r SUMPS I I Distance to nearet: Waal _ Foundation Propony Lina <br /> DISPOSAL PONDS I 1 <br /> I hamby cenity that 1 haw prepared this application and that IM work.11 M done .accordance with San Joaquin county ordinances.stab haws,and <br /> rules and f qulabore of the San Joaquin Local Health District. <br /> Homo owner or Ioened agent's Sgnatun cer"Oft the following: "I comity,that.the pMamancrs of tfta*CA tot which this penins Isatbd.I shss W ` <br /> 'I employ any person in Such manner as to became subject to workman's compensation 4ws of California.-Contractor's hiring or MrDmntnctkl0 agnaMe <br /> unifies the following:"I certify that in FM pedomsroe of the work for which this permit's Issued.I&hall employ pen ors sublec[to workman's comps <br /> tion laws of Caldoaw." <br /> 1w�y'F <br /> The appRcaril res <br /> 0 drwi g onpare <br /> a <br /> 'v Slgnod T.. Deb: <br /> »j <br /> FO pEPARTMENT USE ONLY <br /> x•r Application Accepted by l"L�-/( 2Y �' Dab Area <br /> Pit a GroyyS Spep1 Date Final Inspection by Data <br /> Addhwnh p//t(ys s: .Q <br /> (7 Sit, x-6781 Cl Lodi 369-3621 AD Manlec 7101 0 Tracy 63563 <br /> Apph"m - Paquin all collas to: Environmental Health Permit/Samicas 1601 E. Hwa ton Aw., P.O. Boa 7008, Stk., CA 81201 e <br /> ff[ AMOVNT DILE AMOVNi RFMI TIED RECENED aY OAT% PEPMtI NO. <br /> INFO CASH <br /> N.MCNi' / pgf <br /> 1O <br /> :� lea re)• — <br /> P _. <br />