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F <br /> # APPLICATION FOR PERMIT <br /> f SAN JOAQUIN LOCAL 14@ALT14 DISTRICT <br /> 1W1 E. HAZELTON AVE., STOCKTON, CA40 10 <br /> Telephone (209)466-6781 a <br /> PERMIT EXPIRES 1"YEAR FROM_t;nTE ISSUED Mfi it7, <br /> A: <br /> (Complete In Trlpl w,,,1 T� ,/y t:. <br /> Cq � <br /> Appiicalron Is hereby madtt In the <br /> Bail Joaquin Local Hatch District fpr a pe+mtl to o;nrotnuct and/of InstallIM work hersM dascrIq�•,,�idll'11Ma�rpticallort is ,- <br /> m:Ido in compliance with San Joaquin-county Ordinance No.SQ for"aW or No,.1662 for vwplpump and the Rules and Rspulsdons of dos San Joaquin <br /> f Local Health Dirtrict. - - <br /> I Job AddiamCItY/�+ —r�AJ� &M Site <br /> PM t <br /> Owner'n Name a-' _ '_ Address _^ Pho ne'. '2 <br /> Contractor's Name No.'If&! _ phry V <br /> TYPE OF WELLIPUMP: NEW WELL U WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> -- PUMP INSTALLATION 0 SYSTEM REPAIR L� OTHER-❑ <br /> { DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTIJAE WELL _ OTHER WELL PETS/SUMPS <br /> ." INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C"I Industrial 0 Open BOrtwr► 0 Mer+tece .Dia.of Watl Excavation DM of WetLCasinp. <br /> �C, IJ'�or.teetic/Frivs4 0 Other <br /> Pack Com!Tr�wy Type of S <br /> 1 Public 0 Other ' [ C3 Delta <br /> Dom+ Typo of Grout c},} <br /> 17 Irripatlon —Approx. Depth (3 Em , by <br /> RepairWprM Do. V' Type OI Amm ,. H./. t3aae mark Darr + . <br /> wru I0structiOn 17 WW Diarnow <br /> Seelirrp MaNrlel Itap 60'1 <br /> : Depth FIYr 1Y1eterfa1 Jeebw ti4') 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIR/ADDITION 13 DESTRUCTION ( sspdc grrtern perir�t i} rblit <br /> pt 'eswer4 r <br /> !'� � � ava9ebb taithht�0 iset.l�� <br /> installation wIN saws: Raadanoe Cormn cw_ Other <br /> Number of Owing units; Number of bodiroonts <br /> Character of loll to s depth of 3 feet:_ Water table depth .4 <br /> SEPTIC TANK Cl Tvwmfg Copadly ND. 4 <br /> PKG. TREATMENT PLT.in Method of Dbpaaaf <br /> Distance to nearest: Wap Foundaeion t' pp "-Line <br /> f <br /> �� <br /> LEACHING LINE ❑ No. 8 Length of On" Torsi length/ + <br /> FILTER BED <br /> s ❑ Distance to riuma:. Wan Foundation Property Line <br /> f SEEPAGE PITS 0 DePtf► gl» ,1 <br /> Numper <br /> SUMPS ❑ Distance to+wrest: Wart Foundation " °> <br /> DISPOSAL PONDS 11lhta �. r .'� # t <br /> I hereby car*that I have prepareQ thio application end that the work will be corm In accordance with San Joaquin county ordinarteer,steer ktnra,—A <br /> and <br /> ' rules and regulkilons of the San Joaquin Local HeDiasdct. <br /> alth ' <br /> Homs owner or licensed apartl's alpnatun tartlfisa the tolorrirtp:"1 osrtify that In the porforrnerrce of the work for Which thispeiirt!'Is itaind;I aha6 not.. t—" ' <br /> employ any parson in such nlertrNr r to becortts aubjact m vwkftwVs conOWOEW"Is"of California,"CorttrocWs hits g a atb•oOrttrec p tti�atare ` <br /> csrtlfiaa tM foNow tg: 'l CW*that In the pstfDrffWVs Of the work for which this permit b Ispred,l chap employ poem wbject to teorlarwt's cprrtpertsa- <br /> ` tion laves of Calliornie." c i fi <br /> The applicant a fa ep uind .Cwr,*w thevdng on reverts aide. <br /> '� <br /> r ; <br /> Signed x Tide: Date: f:)T` <br /> FOR!DEPARTMENT USE ONLY <br /> ApOication Accepted by Deft <br /> �7 <br /> F.' or Grout Inspection by Data Final Ittepecdon <br /> s <br /> kddltwnai ComrrNnle, <br /> - : i Sok 4W-MI . L1 Lodi 3683821 ❑Manteca VS-7.104 ❑Tracy 9368366 T.. z t-_ <br /> At,0-0 Raturn all copier to: Environrilientel Health Permit/SeM*m 1601 E.Haalton Ave.,P.O.Box 2wa,Sok.,CA 962Dt ' <br /> ' I INF AMOUNT DUE AMOUNT REMITTED i <br /> Irmo CASH RECEIVED BY DATE P�IeNT NO. <br /> yI ,r, <br /> .- ., :4 <br />