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<br /> APPI ICATION FOR PERMIT
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> t
<br /> 1N)l E HAZELTON AVE., STOCKTON, CA
<br /> Telephone 12091 466 6791
<br /> PERIV.IT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> (Complete in Triidicate) -
<br /> Apri•calm,,..he,rhv mild-,to the San Jnagctn local Health D-slntt for a permit to construct and'or install lee work hlKem described This applleafion is
<br /> made In corno Ku a w-tr,San.luago,r C•wnty Ordinance Nof,49 for serwagn or No 1REi.o for wrll,pump and the Rules and Regulations of the San Joart on
<br /> 1-ocai Prilth Distnt t p p t
<br /> Job Address a / c. R o rti f�• O - _ City lot Sire_ _� PM ---- .
<br /> Owner's Name /9MeIr e CAA/ TY10 51ij C• 1?-r6 hrro�'. .. FM>r r 9 yA O SfS�
<br /> Contracts •_- Address __ License No. -------_-----PAone--.-- ----
<br /> TYPE OF WELL PUMP htW WELL WFIL REPLACEMENT iDESTRUCTION ,I 1
<br /> PUMP I!+STAI LATION SYSTEM REPAIR ;' OTHER i 1
<br /> DISTANCE TO NFAREST SEPTIC TANK _ SEWER LINES _ DISPOSAL FLO PROP LINE
<br /> FOIINOATION ArRIChl TURF WFLL OTHER WELL.. PITS/SUMPS
<br /> INTENDFO 1 1S TYPE OF WEI I rROR1FV ARI-A CONSTAW TION oPECIFICATIONS
<br /> i !tneluArtal Open Roftr.m Manteca Dia of Well I u aval-on --_-.._._._ Dia.OF Well C eirrrq
<br /> 1' Donesb, aavel Pat lo Tracy Type of l'ayihil S{N'r'dKafKMa
<br /> 1-1.,� 1u'elle 'i h ...`
<br /> fasters, ti.I,IJ,tl tiMJl li,slalitld b 3111
<br /> PubIK. hh,•, Defla 13epfi, 1 I, Nil Seal Tyte of lin
<br /> Repair Woo► Dnnr Type of Pu•^h 1/P [,tab•Wnrk O,+ire
<br /> Well Destruction Well D'amr•ter Sralu+g Alatro" q
<br /> Gnplh Filler Material IDrlaw!A)I
<br /> TYPE OF 51PTII:Wolik Ni W INS7A11 ATION 10PAIR-ADDI11ON/ 11I51RI1Ct1ON IN-,work svvtrim lernvaterl d puhlN:sewer.s
<br /> /� available within 700 feet I
<br /> Installation will lento Re
<br /> o%o4lente Ct,mrrrcial Other ����'' CI 9n&a.'
<br /> '
<br /> Number of hying toner Nomfer of twIlroterns
<br /> Character of soil In a depth of 3 het SA�VJr S c'A/'e Wlrr table depth
<br /> SEPTIC TANK Type Mfg C.Itraa,ty No Con{paetttpanb _ }
<br /> r
<br /> PKG TRtATMFNI P17 I Method of Disposal
<br /> Oman,a to nearest Well Foundation - Propriety Lire
<br /> I E flCHING I INI ✓ No 6 1 cow' Imes G X 3 r X t7 Total Mrsgth sura - -Cop .
<br /> FILTER RFD O,stamr,.,neatest Well An Ioundalen lhfa
<br /> SEEPAGE PITS Oiq,lh S,re Nrmholr
<br /> SUMPS thslan,a I,,nearest WMI Foundahun P-peefle two_
<br /> DISPOSAL PONDS
<br /> 1 hereby certify that I have prepatrf flys applot.atgn and that the work will ler dole K1 a,coolant a with tido.luagum co'mty ordinances, state laws, and
<br /> rules and rngulahuns of the San JoatluNl 1 tical Health OiklotI
<br /> Hume owner or hcnnsed agent's stllrlatune twldies the following I certifv that on the Iwttnrnance of file work for which this permit is issued. 1 shall not
<br /> employ any parson on such manner as lu tecome sublect to work titan s co mpeonsatnin laws of Caldomia Con it ac tot's hiring or subcontracting snpnalure
<br /> corithas tho fnllnwinp '1 certify that m the Iwrlromanca of the work for wh,th this lemnt o,ssoord 1 shall wmldoy liaisons wbfecl to wink man's tomlNNrw .
<br /> hon laws of Caldoroa"
<br /> The applicant mu (All lot all rogutmd inspections Com{dato dnaAong on to.rise side ,A
<br /> Signed x tit i• _- . __ Date ! JL-/6— 9� ---
<br /> 3 7 �t FOQ DEPAR rMENT (ISE ONLY
<br /> AppLtetien Accepted by .�'- - -- _ DoteQ AIN_
<br /> Pit or Grout Inspection by Date Final Inspection by
<br /> Additional Comments
<br /> I Stk 4686781 1. Lod, 3G9 3671- Manteca 823 7104 t 7,acv-tC15Fa3D5
<br /> Applicant Return all copies to Environmental Health PetlyldeSefVKes 16101 E. Harenon Ave, P 0 Do■2009, Stk,CA 91.201
<br /> FFE AMOt1NT DUE AMOUNT REMITTED K RECEIVED By DATE PERMIT 0,17.
<br /> tNFO / — 1 7
<br /> f N 13 11 l oo v • • („/ LSC` �l�/. a cl 4
<br /> 1 1 .+L' i 131.
<br /> I tt 14 20 1
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