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APPLICATION FOR PERMIT 'T08 f� V ) o <br />SAN JOAQUIN LOCAL HEALTH DISTRICT y <br />1601 E. HAZELTON AVE., STOCKTON, CA U % 1 x <br />E Telephone (2109) 486-67$1ly �i 0 111 <br />PERMIT EXPIRES M 1 YEAR FRODATE ISSUt�.ED <br />tt_ Z. JComple+te in TripkA te) , : O -A z' 0,17 <br />Applicatkm is hereby made to the San Joaquin Local Hoeft Oiot&t for a permit to duct andtor install the work herain described. This application is <br />made In cornpilance with San Joaquin County Ordinance No. SM for wAiaps or No -18M for we9lpump and the Rules wid Regulations of do San Joaquin <br />Local He*" D"mrtri t. { "� « .r� - r L �'- , r � � aC G � ++C <br />Y <br />/ y yy ._ JId' / Al J...siJ� J� 07 l�'�G'"I pm' 46 <br />..,_.__ J 1 � `l . L / V . � Y'iti., ,wr -*r t evf SbA. <br />jow <br />Ownses Name - ___ so � �� � -7_ <br />Contractor's Name �i�% 1' License No. Phone <br />TYPE OF WELL/PUMP: NElhf MOLL 0 WELL D DESTRUCTION C3�► <br />PUMP INSTALLATION Cl SlP$TEllil REPAIR D OTHER 0 <br />DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES - - DISPOSAL fLD PROP. LINE <br />FOUNDATION --- A GRICtXTM WELL OTHER 1AIlLL PIMSUMPS _ <br />_ INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Ls Industrial n Open Bottom CI MW"Ws Dia. of Well Excavation _ Dis. of Well Casing <br />i t Domeatic/Private 0 Gravel Pack � � i7 TWy Type of C. WkV - -.. Sparfi60ft <br />0 Ptac , 0 Otis' C3 Dake Death of Grout Sael Type of Grant _. <br />a <br />0 Irrigation-V,....Approx, Derma 13'EnWn'Surface SSW Installed by - <br />Repair Work Llan 0 Type of Pump � H.P. t � Stow Work Dome <br />Well Dostruction 0 Well Diameter "� '�' Sealing Material top i>ti'1 rw----''=., _..... <br />Depth 4 -x _Fjgea JkiaC isi {Bai&.� <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ITE AIAlADDITION C.1 DESTRUCTION 1=1 (No septic system �armitted if pubiic sewer is <br />WAWANO within 20Q f= <br />instaffeion will serve. Rasklence _,_,,,.. Commercial other .�5 L+0_ <br />Number of living units: Number of bedrooms <br />Character of soli to a depth of 3 fast: i L ' Wear table depth <br />SEPTIC TANK. TypelMfy'—d C.apadtlr ' M0. Gorriparrorierlts <br />PKG. TREATMENT PLT.' L;, � N �;,, 1 � t� fWood of Dbp91W <br />� PtapMt� iib_ <br />D13t�rce to F <br />rieeusat'` WeA !rrY Ceswle�tion <br />4 2 <br />LEACHING LINE No. & Length of tis } T <br />r <br />FILTER BED :71 tisane to naarest:Wo8 'Fsuat n f9 -fl � LIM �.., „_` <br />X111141 <br />SEEPAGE PITS Depth ALA lize S rt" ' N " <br />,�..�+LIMPwall <br />0 Distance to nearest: � v FoundetinnY y Prav»�r _ <br />_CistS l. PONDS :1 <br />. __� �........_ ....�a.,...uf ►.. a....... i« .......,...iw...0 aitN. Qsa.i inen..uf a!xu1Ytl'v hrrflA'1Brtrfa$. Bate iaWa. and <br />I nermy cer Try trot I nave prepared Iran 14�tGrWn •rw urea uro <br />rules and regulations of the San Joaquin Local Health District. r- ....., - <br />Home owner or Aeumsed agents signature certifies the foAs3n+ektp: ':I CWWY that In the perform nce of the work for which this permit is rowed. I phall not <br />employ "person In such manner ss to became =WM to we kA w,s cxarrapenaatlon laws of•Coiifornis.- Cow's hiring Cr s!uDaontroctInf! signature <br />certifies the following: "I c ortify that in the perfornmm" of the work for;Which this 0~ Is ioruaed. I shall employ p sa*4e0to vvtfrkrrian's OOMMUS- <br />tion laws of Cawomis." •, rte«-.:: --•' . •• r <br />The applicant Mpg call for at rjaWred inspections. Complete drawing on reverse <br />Si,gn � Title t° '7Cr x`'",� -.a- q6 . Date: �!J <br />CrK0 <br />Application Acc ted by. <br />Pit ar Greiut lits� by ` - Date <br />USE 9PLY <br />% ` �� Anne � •� <br />u`i i - •• 17v <br />Additional Comments: •` *`~ <br />2-1 Sfk 48947$1 Lodi 399-31921 k frow* 823-7104 0 Tracy ! <br />1poIlcant . Return all copies to: Eavirot>menW HOW01 llantfltiS4 Vjm 1801 E. lora Ave., P.o. Boot 29M, Stet., CA 9fi 1 <br />+ V 13-24 IREV. <br />Fiat 14.0 , <br />z <br />