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<br /> i4r't-t.1_.ATION FOR PERM!-E aS►' .,
<br /> SAN .IOAOUIN LOCAL }IFA!TH DISTRICT " ( )
<br /> ,Xj: E. HAZELTOAt AVE., STOCK-101j, CA
<br /> Te::-phone (209) 466.67RI
<br /> PERMIT EXPIRES 7 YEAR FROM ✓ATF ISrUED
<br /> " fCnmplcte in Tripficate)
<br /> Api.Lcahon is hr.toy m;,Jt-to rhe San Jeaqur'.Local Heai'h--s`rict for d per—!in constr,,ct.-Afo: .^.'anh;tin v.ork herein dr.sfr:'uret This JprJ-,calinn+s
<br /> t: °.. - matte#in cnmi'1.,nt'e avith S,rn,lnb'ittin Cn.,nN Ordnanro rip,'.a9 f or sc•,var}e ur N,t. f(iti?fof— '.'p,.r^.tp.yn[7 iha Ruler and Pegulatiuns r,!the_S sn Jnxlurr
<br /> Local Hr.uth D ttr c.. ;2
<br /> m k '
<br /> ...•, id`. Jcb Addn!ss _ r
<br /> Lot�
<br /> h Owner's Nanie
<br /> Address Phr—,
<br /> [ � •'.on Ifi iv t:.LC � I �,.I� r}�1or�:e !� C7. �� J PhofM!4`�/�J���
<br /> E[ 4 TYI E OF 1 FLL/PL'A1F NEW WELL i' WELLRFPLACEf.tENT DESTRUCTION i.i
<br /> P
<br /> �= L'M•'fNSTALLATiON ; :ySTEM REPAIR OTHER F1 ,
<br /> _DIS1ANCE 10 NEAREST SEPTIC TANK - SEWER 1.14ES — C'SPOSAL F;0.___ PROP. LINE j
<br /> ' - FOUNDATION ,.. . AGRICULTURE WELL U lHER WELL _--_— pITS/SUMPST 19
<br /> INTENDED USE TYPE.OF WELL PROSLFVIAHEA CONSTRUCTIOf.!;rFC.IFV%ATI0N5
<br /> g 't ii. t..t indu.irvl -.1 Open Bottom l]M intoca Ura. of Werl Excavation - _ �,. -_, Cia.of Well Casing
<br /> "i,, Domest,ci Pnvare G•avef Pack (:1 1,1 cy Type of C,,s;ngA__ __--. —.._ Spec,ficaticns
<br /> ,q i-1 Public 1-1 Olhcr I i Delta Depth of Grout Sea' Type of Grout—._—.��—....,. IC
<br /> x r
<br /> d - 1 I IHrptUDn Aplrrda.Depth 1 I Eastern $urtdGn Seul Insedlim!7V
<br /> s tti� a " Repair Work Done t 1 Type of Fiji H P _ Slate Work Done— __
<br /> C
<br /> + � �
<br /> Well Deatroction 1-1 We:.Diarnotor .—__ Sada+g Material itup!i/J't _ p — —p111a�
<br /> i Gepth Fillet Material(Rulow.,0' - ---
<br /> r
<br /> .�_
<br /> 1 YF'F;OF SEPTIC W(1RK: NLVJ INS tAI,LATII.N 1 1 HE'-AIR/A0(71 i1L1r `'J t DtfHl1CPGN I 1 (N,,se uc system vmrnef d le.wor is
<br /> within 200 feet.)
<br /> installation will serve: Flerkience.-- Conl e-cial. -
<br /> t st`, Number of living units! ------. Nurnbcr of bedrooms'_
<br /> - _ _ Water table depth
<br /> Charur_ter of Foil to a depth of J feel' _ -- --/-
<br /> SEPTIC TANK I"' Type/Mf n ..``'L'(- ap�autY I p
<br /> g NS'.t�CF+:�..j._aC4,..._.—._ -(!T•'C___ No.Com artments _--
<br /> PKC. TREATMENT PLT.I:1 Method of Disposal _ _ —
<br /> J D.slanco to nr'a•est: Wail _— Foundation Property Line
<br /> •4-' ;c, .. 'may�,���_ t _
<br /> ' (.CACHING LINE; f.&--No.A Length of ones J_.�?�'4`---t-- T-
<br /> I 1 Dstan c to nea esr. yL ee Foundation Fhoporty[MAI
<br /> ' PITSSEEPAr —•--- �^
<br /> /—._.--
<br /> SUMPS W Darance to r Barest Well —_ ___ F n.ndaGon�r1L ,'rojw W Line��..._
<br /> i .DISPOSAL PLc'DS
<br /> ( I hereby condy toat 1 haves;treparod this appttcat o•rond that ttto work witl ,e dorw ut accj.d t.ts wr,h San::Mquin county o+dinances,state ktwa,and
<br /> t r f rules and regulations of the San Joaquin Lo al Heat:',031fict
<br /> yyy�
<br /> Home owner or e +cend%Item's sx)nant,o-nit.-.,the following:"1 certify IIIft.n the Perforrnt r af.aha'rock lot which this 0.crit is issued.I shall not
<br /> e employ any Dorson in such" -,nef-to herome Buhl—ir to wu:km m's compenshutn W s of C.I( rrva."Conractor's hirdng w suo-co.itrxting sig:wfurn
<br /> r` - certifies the fotlow'ng: I rt:,y that in lhi pedryFr;ar.ee of the work for wine'd,s( ' ns,e+.,.shall mploy(ersons sut;act to workman's cornprtrisa
<br /> W r `.tion laws of California."
<br /> Tho apps nt mus for all requir oactioi r• oto Drawing on rover ASN
<br /> �—
<br /> d �- d%rCcL� Titin:_/•Sf..l .c.+i�—�._.-_. _— —___ Date: Dl�
<br /> FOR DEPVTMENT JSE ONLY — 2
<br /> i 1
<br /> Area.
<br /> Application Accepted by �f --
<br /> Pit or'irout Ir-p•-tioal by ----_--- MIT"_..__—_—_— Firel Ins;ctton by Dat a_', _
<br /> Add'tlonsl Comments: _ � ��a .vf�:!t
<br /> ( 1:T Stk 4%67!'1 f.:Lodi 3Gy3G2t E�Vlw anleM 7'04 CJ Tracy ffiff315 \i {�. ,
<br /> Applicant•Retum al',copies to:Environmertal Health Pormit/Services 1601 E.Herehon Avo., P 0. Bo■20(b,Sti.,CA 9.`7201 -fu
<br /> rF'- AMIIF I AMOUNT RCMI^Ei. CK RECEIVED C" DATE PFPM(T
<br /> OUNT U
<br /> INT 07�7CASH
<br /> (Y.142%
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