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r � h <br /> APPLICATION FOR PERMIT "- <br /> SAN JOAQ,UIN LOCAL HEALTH DISTRICT <br /> -w <br /> 1601 E ' TON AVE.' STOCKTON, CA <br /> E. HAZE <br /> Telephone (209).468-67 t'. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EALT <br /> q j 1- Aj (Complete in Triplicate) <br /> Appl tion is,hgreby to the San Joaquin,Local Health District fora permit to construct <br /> 'and/or the workherein / a4p1 !s <br /> obi ` i�rp#a wh1Y JoequwCounWOrdinance No.549 for sewage or No.`1882 far weH/pump ani the ReQIM1 a�f iia Seg"Joaquin . <br /> Local Health D _2r;i�.; _:,Z � <br /> :. <br /> p#rf <br /> 5 S <br /> CPQ I Lot IR <br /> _ , a <br /> Job Address - ` r' rt1!t -, <br /> . 489 RjlvelPhone <br /> rT �F $ VwF1R� <br /> Address O� `� w - ...A-X— •.'nes - ky a .,r. <br /> 04 'a7>993 340 <br /> License No <br /> ContAddress <br /> ; <br /> ` NEW WELL WELL REPLACEMENT ©,' DESTRUCTION © h <br /> 7YP OFWELL/ <br /> m h kr �4 g�Ak 4 <br /> + SYSTEM REPAIR O <br /> PUMP N5TALL1� FLp p y > <br /> f <br /> , <br /> t r <br /> TAN , 35POSALi � LTfTNEA18T SETC'FOUNDATION AGRICULTURE r <br /> WELL OTHER WELL ""tr• SLN1 ` <br /> Ir r INTENDED U5E PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TIONS, <br /> i _ _f _ <br /> u open <br /> Bottom ❑ Manteca Dia. of Well Excav Dia Wef <br /> ustBel Pe <br /> dy - - 7 k <br /> Dirxsestia/Private :p ❑ Gravel,Peck-„ Q Tracy Type.Qf CasifC{�±G VA�•a <br /> w ❑ D Depthief.Grout$eat k " "�^;-• <br /> sr 'Publ� ! ❑ Other alta <br /> 1 r -^"' RppYoic tFi Eastern Surface Seal Installed by r <br /> 3 k' . <br /> i° £~ State Work Donn �i <br /> i R r Work Done b Type of Pu�p ,Sea <br /> P. <br /> WeII.Diame �, Healing Material Itvp 5U 1 <br /> I x "'r r Weil Destruction ❑ <br /> 1 <br /> _.,..,., . Filler Material (IMM <br /> s� E 17epth <br /> i /ADDITION Q CTION ❑ INo septic sy:l <br /> PE IxTIC iC NEV1l,ENSTALLA7ION ❑.;_REPAIR,~' <br /> Mme^ p,�+, - r i•% available W111H. <br /> - �� '! d rim <br /> a <br /> aZI <br /> latstailattodtseapr aidenase 6Qmmercial Other , <br /> -y 1 <br /> 't M .0. 'Number Abedrd mS <br /> s� l �^Vlf�ata tlkib depth <br /> y • . EPriG' Ac t arQ�pth of 3 feet: <br /> Charaete n <br />' ❑ „ Type/Mfg pacify <br /> .Ca No <br /> g'rai <br /> j h '�� r rPKG TREAT EI T PLT ❑ i. tNethod,of Dispbael <br /> ak r� Distant a to nearest: Well Foundation Property Lane <br /> t c <br /> LEACHING LINE © ..No..& Length of lines <br /> Total length/size <br /> � r <br /> �a1 l=l�.Tl BSC? ] Distance to nearest: Well Foundation Property L <br /> na <br /> �N u <br /> i z - ., <br /> n $EEPAGE PITS Q Depth Size N - <br /> i y <br /> umber <br /> i &.. <br /> # # ,Sl1MPS ❑ 4ista6ce to nearest: Well F d <br /> ootids �on'. _ <br /> .. Property Luta� 4, <br />` s DISPosAL,PONDS . ❑ <br /> l ' l'heroby certify that I_have prepared this application and that the work will be done in accordance with SanlJoaquin worst~ordhiarx�s,stetef and _. <br /> s. <br /> .r totes and regulattQns`.of.the:San Joaquin Local Health District. .i � <br /> �14 Hama QwnBr or licensed agent's signature certifies the following (_certify that in the performance of the work for which this panni[. a' <br /> a , � y j pin it CFi marrr tolbvoom4 subject &workman's oompensatwn laws of California.' Contractoi`B hiring or <br /> subcbntrartfia9,aignarture ; <br /> �5� i,; certifies the fQllawirig '•I certify that performance of the wank for which�1s'parrriitfia I shall employ persons subject to workman's tmpetr9a - <br /> e tion laws of.Califamia:,,, �. <br /> { applfa;a call for ail, wired.inspet tlbna.,Complete dravumg on reverse s de. <br /> f F r <br /> Title> G I �► Date. <br /> Eh S4 a' Signed , YV ,� ! or <br /> EPARTME111T USE ONLY , <br /> g, CYiit;r• ►k. RMi!+ pate1I.;S2 <br /> AreA x 1 <br /> Application.Accepted by <br /> i p Final InspeCOM <br /> Pit or�Grout In i' by Date r♦„m2 y wr r J wr' p p t l J l µ/kdditioaral Co r <br /> mmenta , # ; <br /> ❑ Lodi • 31-3821 ❑ Manteca 873-7704. Tracy s 6` <br /> ! 1811 E. Hazelton Ave PA Boz 2108 Stk. CA 98201 <br /> Retalm all copies to: Ermronmerital Health.PermklSarvicea l <br /> QP E <br /> b <br /> ` INFOrs ' fi� AMOUNT DUE AMOUNT REM( ED CA8H' RECEIVED BY DATE <br /> - r:.. ... <br />