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<br /> .� APPLIi:tiTI0r1! FQR PERMIT
<br /> SAN .I0AOU1#: LOCAL HEALTH DISTRICT
<br /> 1601 E. HAZELTON F.V:i., STOCKTON, ,� •,�?'A.�
<br /> Telephone 12991 466.6781
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE©
<br /> T
<br /> ----- -IComplete i7T Trirlicatel C '
<br /> Application is hereby mads to the S:+n Joaquin Local Health District to•:o!rmrt to construct ano/or instal!the work heroin de ir**t�1Tl'�a;.p!;catien
<br /> made in compliance with San Juda::in Coun:y Ordrnanre No.!rs9 for sewage or No !7:(12'ot v.eq/ptimp and the X11 s':"ttls �. 'e�T the San.}paYu,n
<br /> Local Health Dislrct. `i„lt:rte �•r�., ,L.C�
<br /> {l4 i�•.'1.l.
<br /> Y Jot Address 221 6 City_ lcl%lt�rte_ l.ot Site-� --_ Phil --
<br /> ,t Golden Grain Co. { 435!
<br /> K Owner's Name Add:e.51_lAL-1-39th_AV-ft,--Sara_.Leandr,"one
<br /> i
<br /> 1401 Halyard Dr. , Ste. 140 (915)
<br /> Cont eclat ovndwater���}lric ( ]iEst�aCr�3Uanta,�. Litensc: C5-2-=4342bne 312-97A0=
<br /> TYPE OR WELL;PUMP: NEW WELL :G L'JELL R'.f'LACEh1ENT i.1 DESrRLICTInN (.I
<br /> k PUMP INSTALLATION Ll 5Y5TFM Rr.AIR 11 OTHER 0
<br /> D1S'rANCE TO NEAREST: SEPTIC TANK -- E CWI R LINES DISPOSAL Fir). �-_ PROP. UNE
<br /> ?�---- PTS/5VIMPS
<br /> : FOUNDATION S AGRICULTURE t 0. ER WELL_
<br /> r !'41TUJDEO12SE TYPE OF WELL PROBLEM ARE-k CON57RUCTION SPECT=lr.AT70NS
<br /> �, X1Gndustrial Cl Open Bottom 1 Nianloca Dia. of Well Ericava:ion_ r5_'_ Dia. of Weli Casin_ -
<br /> tr
<br /> fl AameiticrnrKatc LX Gravel Pack [a Tracy Type of Casir.gY?yL'„^_--- 5persilica+ionsC:eIDent
<br /> ('i PuLlic I'i Other f7 Delta Depth OI Grot:t Sc.,i Type u! GrousgrLd---.__. iV11 J.O."Apps. Deptt, I ? Easte+n S-rrfdce Snell Istalled bySi,le Work Done__
<br /> 3 Repair work Dona IJ 7yp�e of Pump � _ H.P. ------- - _�
<br /> Well Destruction fa Wert Diameter Sealing t1late6al(top 50'1
<br /> i
<br /> Depth - - Filler Male,ial IB••Inw 50'I
<br /> ` TYPt OF SEPTIC WORK: NEW INSTALIAfi0N ! —int=F'Alii!ADOITlI�:, 'E.r.1RUf,710N 11114o Septic ayarom i-,vrmnted'rt puWrc xw.:r u
<br /> i availab!c wnla.r 200:eet.1
<br /> h _
<br /> Insr3flation will serve: ResiJrnce i omrs•c,al_ Othe• _
<br /> qi
<br /> Numbe.of living units-_—_ Nun:Ser cl.•edraams
<br /> Character of sal:to a depth of 3 fest: T_—_. — ___ —Water table
<br /> ry sto SEPTIC TANK LI TypeJMIq — Crpacity __ No. Compartments
<br /> 4 PKG.TREATMENT PLT.C A!ethod of Disposal
<br /> Distance to ne.rest: Well _ rp,•illation_--- Property Line _
<br /> QLEACHING LINE No. & Length o1 tines _ _ __ _ _ "vial leoi,11i/site_
<br /> r FILTER LED Cl Distance to tvwaresi: Well _ ._ Foundation_-- PFONny Line_- -
<br /> - � SEEPAGE PITS I I Depth - Site—__- -�.�-- Number__ �-��- -�'•_.'^
<br /> SWAPS 0 Distance to ne+arat: Well___--_ Fo..rdat on _r Property Line
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<br /> DISPOSAL PONDS (7
<br /> I he,aby cen,ty that I entparee this application end'hat the work will L»r Cone in acct rdancR with Sar,doagcin county ordinances• state laws, •snd
<br /> 4} lutes and regulations of the Sa+:.r-aq,in Local Ilealih D•s:rict.
<br /> ;.; H(+me owner or licensed agrfni'r g7nb!L.xnifies Tt-V 1n:lowin0; "I re:r!y!hat in thr performance of the work for which this permit is issued, 1 shall ror,
<br /> employ any,xsen in such mannr,r ae to.,&CU.M-tU!;cot:a warknlaft s cornr,"w inion laws of California."Contrar,Df'3 hirine Or sut-cont,aetinp signis ru
<br /> l r,}rt,'•lias Ina following:"I ranify thr;.'ii, ;ta poiformanee r•f the work Int,v13ir i:hie•permit is issued,I shall Mrpl:y pe+sons subject to workman',eernlx►st
<br /> f Con laws of California." CAN JOAQUIN LOCAL HEALTH D)STWI
<br /> The appli, i est rail for atl roquirad i.rspx-tif�,ts Ca.nplalo dryw.;nq:,n rtvursv sidi. EyVIRGNMENTAL HEALTH DIVISION
<br /> 7 --:-s30�() 35t I Vi "FR> TP99
<br /> Signed J �Y ^4Otr
<br /> SPECif
<br /> I FOR DEP:MM.ENT USE ONLY
<br /> i �f'1JI(ec l7_
<br /> Application Accepted by JdI� �` -- — — ----- Date
<br /> k' -3 Area _
<br /> f Pit or Grout Inspection by Date r Firm} Ins;fiction ty �•-Y—C-4—C-4 Date
<br /> ! Additional Comments: --- _. -- f —
<br /> O Stk 455 737 ❑ Lod: 365-3621 0 Manteca 823-7104 0 Tracy 83;•6385
<br /> i Applicant- Return all.spies ic.. Envirc•tmonal Health Permiv Ser%kus N,O1 E. Hetalsar•Ave. P.O. Bus 2009, SA., CA 95201
<br /> I _
<br /> i IFEE NFO AMQt,NT�DUEE AMOUNT
<br /> 'FEEMITTF,C CK H �RiZEIVEt7 By DATE (�PERM.1 70.
<br /> t; . Eli 13-N
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