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c� 1 <br /> APPLICATION FOR PERMIT <br /> O b `w <br />� SAN 3OAQUfN LOCAL HEALTH D15tfifCT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA '. <br /> Telephone 12091 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t (Complete in Triplicatel J " <br /> Applieation is hmeby made to the Sen Joa4uin Local Health District for a permit to Construct and Ior install the'work heeein described.This apptitation fy J <br /> made in corrpliance with San Joaquin Cowity Ordinrnce No.549 for sewega of No. 1%2 for wellIpump and the Rules and Regulations of the San Joaquin <br /> i <br /> Local Health District. <br /> Job AddrEnss City lot Sita PM <br /> r.. <br /> 00, <br /> Owncr'a Na - —�� Addmts <br /> Phone v� <br /> f <br /> 45�- Address �Tf' Pfiorne <br /> TYPE OF WELLIPUMP: NEW WELL 17 WELL REPLACEMENT ❑ DESTRUCTION l] $ ' <br /> PUMP INSTALLAf10N Ll SYSTEM REPAIR 0 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES._. DISPr}SAL FLO.-- PROP.LINEy y <br /> FOUNDATION ___. AGRICULTURE WELL ._ __,OTHER WELL— MTSMUMPS ..., f � jr . <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ f <br /> L7 Indust" CJ Open Bottom C1 Mantoca DIa,of WON E"Cliv ltiOn w ...,,.. Ola.of We%C"kv 4 : _.•. <br /> El Dorms6c/Private L3 Gravel Pack i 1 TfacY Type of Gtkv ., Spat ta> ► <br /> i'I Pu41k, I1 011ier I.l Deka Depth of Grout Sea! Type of Grow <br /> I I Irtigetlon _Approx. Depth I I Eastoin Surface Seal Installed 11Rt - 1 <br /> Repsh Work DOM Ll Type of Pump _,_____ H P, Stets WtNtt Done <br /> Well Desitruction 0 Well Diameter Svaling MOMI&l ItOp 5D'1 ' <br /> .Depth _ Fu&n Material fBabw wl <br /> 1 TYPE OF SEC WORK: NEW INSTALLATION No fit 1',+IRiADDITION I I DESTRUCTION 1 I iseptic ��ted it public hewer is <br /> PTI ,fie <br /> i ,f aYall3Ala 11M11nN1 ) � � a' ��'1.` „ <br /> ltratariatien eY1M tatrro: Residence <br /> Nwnbsr of aNh+q units: Number of <br /> 4 Chiewtar of sol to a depth of 3 feet: oo <br /> Water ta4M depth 5 <br /> SEPTIC TANK TypelMfg <br /> PKG.TREATMENT PLT.1.1 Method #� <br /> Distance to rarest: Well�_t� #eu►sdatkon..,.�., � PEgEerry two <br /> LEACH114G VNEX No.N Length of Ilnae <br /> } <br /> FILTER SED Cl Distance to naarest: Well . 5-' FOundatlon _ _proOaE LIrM <br /> SEEPAGE PITS Depth w .s Sire____ • Nurteter ` ' �• <br /> 1� ,_.. ----- <br /> SUMPS E.1 Distance to nearest: Well t oundatiOrf PEE PPV Lina <br /> f DISPOSAL PONDS I_-) <br /> _- - . <br /> I hereby eMity that I he"prepared this application and that ilia work wlh be done In accwdvrCe with San Joaquin county Ordillano s,state laws.and <br /> rules wid regulations of the San Joaquin Local Health DAlrfct• s +' <br />( Mims owner or licensed agent's signature certifies the following:"I Cattlhl that in the gerforrnanea of the work foe wftkh tis Owlish Is.hsuod.I Shari not <br /> ft ar sub employ any person In such marn+er as to hacwne subinct to wnEkmen'a ooEEKf satlol+fai+e ei CaEhofnis."Contraeso+'s Inleirtp oasmctir+B 1119-ft" <br /> certifies the following:"1 certify that in the performance of the work for with this poll th Ix Issued,l d+>dl employ pwaarEll aubleet to rrpkman•Corrtpanaa a. X ., <br /> tion laws of Cal;fomli." <br /> A t. <br /> The eppticiElt N for anComplete drawktq en reverse .sy <br /> Signed X—� <br /> rOR D ARTIUENT USE ONLY q <br /> Applkatlen Accepted by Dan ArN pp+2 5 <br /> 6 m Grout Inspection by ! �IlkHlectbn by . <br /> Additional C wnnwnts: -- <br /> Ll Stk 466.6781 0 Lodi X9.362I IJ Manteca 8237104 E7 Testy 835.6385 4� : <br /> i Applicant-Return an copies to: Environmental Hna+th Parmit'Sorvloes I6D1 E,Hazelton Ave.,P.O. Box 2009, S*,, CA SMI <br /> }FEE AMpi1NT DILE aMOUNI n{MtTTt:o CASH EIfCEEVEIy RV DATE pEtt�El'HP. <br /> If <br /> . EH <br /> 1 <br /> 7 T�1atV.f�RS� r (,,, a�� <br /> rH 14:e ._�—.... <br /> .i <br /> 1r <br />