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w <br /> k <br /> F <br /> 1 <br /> APPLICATION FOR PERMIT <br /> y d <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT!!pR; <br /> 1601 E. HAZELTON AVE., STOCKTON, CA - <br /> Telephone (2091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 't-"' ` ,• `" <br /> (Complete in Triplicate)[ <br /> Application is htleby rnede to the San Jooquin Local mmig,D'etrict for a permit to construct and/or WW311 the work heroin described.T;ea oppRcetlon k <br /> mode in compltanrA with San Joaquin County Ordinance No.649 fa sewage w No.1962 for wee/pump and the Rules and Regulation of the San JoepUin <br /> Local Health District 6 <br /> Job Address Cityt Sin of 'L PM <br /> Phone, Z <br /> Ovmer's Flertw.- (c 1-It!>_- `ti-Ez-ti- Address <br /> Address-___ Lcense No­__Phone_ <br /> Contrxcor_-5- G_ ._---- ., <br /> TYPE O�WELL;PUMP: NEW WELL 11 WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.__- PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS -_ <br /> IN`fENDEC USE TYPE OF WELL PROBLEM AREA_ CONSTRUCTION SPECIFICATIONS ---_ <br /> C'IntluttMl ❑Open bottom ❑Manteca <br /> [)is.cl Well E."wRion — Do"Of <br /> WM VV*"r <br /> C Domes-.ic/Prb16te C Gravel Pack C Tracy Type of Cosirp <br /> C Public D Other C Deft Depth of Grout Ssal _.. TYPO of Groin <br /> C Irrigation --Approx.Depth ❑Eastern Surface Seal Installed by_ ---------- ---` <br /> Ragan Work Dane L' TYpr.of Pump _— <br /> H.P.__ State Work Done <br /> War:'•nnuction Ll Well Diameter Sooting Material Itoa 5D'I ...-- <br /> nw,Mh_-- Filler Material(Ill ail1 — <br /> TYPE OF 'WORK. NEW INSTALLATION❑ REPAIR/ADDITION DESTht_CTi(1N - eNeaa"PtiCbke iathM'MM 1lntlad„Pubkc nweE W <br /> lmb,reli will serve: .,fdamgCthr <br /> Ifni <br /> _- rc191_ e <br /> Number of King units:.,e1_ Number of bedrooms WeMr Able tkgth <br /> CMrottm of sole w a Moth 0 3 fast,-�-� <br /> SEPTIC IANK X Typt/Mfg 1 t-P# _ CapaclN-1�� Nu. Compnto,ents Z------- <br /> _-- <br /> PKG.TAEATIdErIT PLT.❑ Method of Dlapoeal <br /> Dii to margin' Welt FaunMtion Property Line- <br /> ___\rtl t- - Total length/ <br /> LPACMING LINE � No. I. Length of line -�. <br /> FILTER PED [iDistance to MaiWali \ FOUnMtion_.___ Property Line__-- <br /> SEEPAGE PITS ElDepth Size Number --..--. <br /> SUMPS C Distance to rearosc well_— Foundation ,.Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereoY Wr4fy that 1 have prepared this applicelior,and that the work will be done in accordance with San Joaquin county oMinancw,stMe tests.arta <br /> odes and rugul rtiorn of the San.:bequin Local Health District. <br /> Hwra owner w licensed agent's signaNn certil'es the following:'"f certify that in rM performance o/the work for which Ihle pemdt la 3asHd.1 shall rapt <br /> lub�V`Ncft Sig <br /> employ airy person in eu^.h rnmier as to become! blect to workma::a compensation law's of Ca1HprNa."Contrect%e�hvwjb*tor to workman's ccomporb' <br /> certifes the faaooAng."I certify that in the Performance of the work for which this Permit La round,13";l empty Oar <br /> :ion lawn o1 C-MOMie." <br /> The OPP'rw s2�,Ic ell for all <br /> tequ/i�'d in tbna.C•xnpleta drawing on renins uda. <br /> �e �7./_ (` 1 oC __�. Date: <br /> Signed _ask.._.. 1The:-LAEa.-_ �FOR DEPARTMENT USE ONLY <br /> C -� A w" <br /> Application Accepted by r '-------- Date <br /> Dote F1ne1 Impaction by Deo <br /> Ph or Gnwt Inspection bi, _---- q <br /> Additional Comments: <br /> )�Stk 466-MI C Lodi 369-31521 ❑Menten M7104 C Tracy ,B;S6J86 <br /> Applk:snt-Rstum all ccWias to: krvironmafnel Health Panni;/Servbss 1931 E. Herthon Aw., P.O. Boa 100,Stir., CA 9Ei2U1 <br /> b FEk AMJUNT REMITTED Rc=k- <br /> vuc <br /> CEIVED eV DATE FPIRmLriNO. <br /> OMOUNT DUE '/I <br /> • EH Ills IRfv,x'n� '!d sob O O -- -7 <br /> .",.,v Ar S_L-14 e4? _- <br />