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APPLICATION FOR PERM1 ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA y <br /> Telephone (20®)4666781 <br /> } PERMIT EXPIRES 1 YEAR FROM DATE ISSUED =` <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sen Joaquin Local Hamm Dbutl for a permit to cautruet and/or Install tate wo-k heroin <br /> mads in compliance with San J did This sl>ppaleon.is <br /> Local Health District, Joaquin County Ordinance No.54g.tor eervega or No.1882 for wail/purrgt and the Rulee NOW Rpuytlpns 411 11111119 gen Jeagtrit <br /> ;. Job Address �R ti C-l" V p:.:..� city—�7rS�' Rot sins.�C u,._PM <br /> ! - .. <br /> i Owner's Nam, e, Address ' d v <br /> s w Y <br /> k <br /> Contractor Address_ �f SO 4 FIS Emnyl 411 icense'no.-a-y5:4 I? Ph" <br /> a <br /> t <br /> V,r TYPE OF WELL/PUMP: NEW WELL d WELL REPLACEMENT D DESTRUCTION O t r <br /> PUMP INSTALLATION 0 <br /> SYSTEM REPAIR fl OT}fERq Ci:. <br /> F !$ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. pRpp„Ltf <br /> ` <br /> £j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 3 INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> N CJ Induavial # a <br /> ©Open g0lt0r>1' ❑Manteea Dia.of Vft Excevation Dia.of Wstl Caairrg <br /> 5d Domestic/Private CI Gravel Pads - 0 Tracy Type of <. <br /> Cl Public Qthen l7 paw SDeGRca�lorgt <br /> Depth of Grout El <br /> "TYPO d Greta <br /> L3 Irrigation - <br /> .—APP!ox.Depth ❑Eastern �.. SuAaoe Suet Msta9led by <br /> cy ? Repair Work Done X Type of" _Z;AL H. <br /> _�� stabs VYarlt Dana i <br /> Wali Destruction 17 Wall Diameterr yE <br /> St dre Material(top W) 7 <br /> Depth FillwMetmiM(6.bw 60) ^� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑• REPAIRlADDR1pN O DESTRUCTIONEl lfb e+piic ttyttterrt yr <br /> swan"within ZOp tMt,l pt C sewer it <br /> '• Installation will serve: Residenea_ Corntrt>srdd Otl>sn , <br /> Number of living trnhs: Number of bedrim tea <br /> .' Character of soil to a depth of 3 feet: ' . <br /> SEPTIC TANK CI Typo/Mfg tAfater table depth <br /> Capechy No.Compartments:: <br /> PKG.TREATMENT PLT.❑ - <br /> Method of Disposal <br /> Distance to naarep:.: Wall Fowxtff art-.�,._��ply Llrn <br /> ,.: LEACHING LINE 0 No.8 Length of Ones Total ! <br /> FILTER BED N' <br /> Distance to rtesrort WsN Four>dadon` Propmty Lka <br /> SEEPAGE PITS 0 Depth sinNueel6r. <br /> SUMPSB Durance to neeneat: Wes F plyLim r � ` <br /> �,t DISPOSAL PONDS Q <br /> rI hereby certify that I have prepeed this eppBCation and that tha work nMr be done in <br /> ,�,, rules and regulations of tin San Joaquin Local Health Dist ict, aoaordr>ce Wier San's a 1.stl sa*ms.lr>0•. r <br /> . Home owner or licensed agarrt's spnsture certifi 3 the f*kwing:."I earthy that in the <br /> c employ any person in such tin ww as to bora 0 subject to 1Malkrtlall's I IC0111ertoe COd the work for MAtirh this petfNt is Iswtsd�.#do rqt' <br /> ' certifies the f awnp oatfan ttlwa of Caefort>h."CarmacWs hirktg cw <br /> a CNowir>g:'9 tnrtifY that in tin perfonrgnoe of the wok for taAticlt this pernnit is ittnred,1 chap antpby Pjt>grte s>bjsct�>Mafomntrs oosrtpr <br /> tion larva aof California.,, <br /> The applicant must cab for ab <br /> r� nqulred inlpeCtlpl>e.Car>tpMta drawing Crt eeYaree eid�." <br /> Signed Tie. <br /> AR7'MMT.USE ONLY <br /> ] Application Ac <br /> I.M1... _ Dam aft <br /> Pit or Grout In <br /> Additional Comments: <br /> L7 Stk 4613 8781 Lodi ,388-3821 ❑Mwmm US-710/ O Tracy 8x4m <br /> Applicant- Return all copies to:Environmental Health PermwSevvipsa IBM E.Haselton AW,P.O.Batt ,Sok,CA r '_{ q r" y x <br /> AMOUNT <br /> IN O AMODUE AMOUNT REa1r11FD t H �wv tleI1TE. l <br /> 'C` # 5� <br /> ow M0. ,r <br /> f,,]13'lAIRtv.ln51 - - - 4h <br /> pi 14.2d <br /> 11 e.S .. <br /> pq b �3 <br /> X . <br /> ' ` ly�-{ • <br />