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<br /> ' APPLICATION,FOR PERMIT.
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> 1601 E. HAZE1.TON-AVE. STOCKTON"GA
<br /> Telelahone I269i 4G6-b781 I
<br /> 1 } PERMiT:E7CPIRES 1
<br /> YEAR:VP W..;I'3ATE ISSUElb
<br /> sr ty� +'1.
<br /> [Complete 3n.TripitCate) r � 9 6
<br /> 'l Mkt a !I r��rn ,s
<br /> h Applicatbn is hereby made to the San Joequlrt Local Health Diorli,K for a Permit to construct and/or inttell the work herehl tleiCribs�. ■� �'
<br /> made Tri eompllance.wlth San JoaglHn County Ordinance No.CA9 for suwegs pr itor Ito..for well/pump and the Rules end Rtsgulatlorte of the Sssn Jd+quih r
<br /> Loctil Health District
<br /> ,[ f C Lot Sue t
<br /> FM f f
<br /> `Job Address nY
<br /> Chvner a Name Address Phoria �«r
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<br /> f i15 _ _.PEi'rl�t _ }} l
<br /> +,.. t hContrador, tJam$,l Licence No.
<br /> WELL REPLACEMENT G7 DESTRUCTION.❑ I
<br /> s� `�, -';iTl(PE WELL/.PUMP: ;Y - NEW WELL l� {
<br /> INSTALLATION ❑ l SYSTEM REPAIR f] I, OTHER a
<br /> rI PROP LINE i_
<br /> �f,•t�yDFIITANCE TO NEAREST 'SEPTICTANk SEWER LINES i = D15PO5Al FLD
<br /> FOUN014TION 'A31,fCl1LTURE WELL 'OTHER WELL P1T9/SUMPS f'3'
<br /> y f INFENCE�3.USE TYPE O> WELL PROBLEM AREA {CONSTRUCTION SPF&ICATiONS
<br /> Y� + - ,
<br /> �.I{'industrial []Open Bottom ., f7 Maniacs , Die:of,Wall Exeavatl8n Did..of WNl Ctleku� 1}i
<br /> #!:; " QiDomestic/PNvete C7 Gravel Peck 0 Tracy Type of.Casin SpeoS+Ieatlone
<br /> ❑ Pub�li 0 Other ' 0 Dolts i Depth of Grout Sealy �- Typo
<br /> x Depth, {3 Eastern Surface 5eai Instni3ad.bY s +'+I= N wr.
<br /> -�, i ld r rr '
<br /> i}� J Irrigation i rAPpio pt . { r + t wi Y y.
<br /> `3���Rayh�r Work Dore 0 Type a1 Pum -- H P State Work Dane
<br /> Ij Well+DefhucGon r� Weil Diameter seaYtg'Material-ftapi�o 1, }
<br /> r ,i +
<br /> 1 i
<br /> Depth
<br /> t i, FIIIerIA�leter�af(Bs1o�v
<br /> PE OF.SEPTIC,WORK NEW INSTALLATION❑ REPAIR/AD ,DESTRUCTION El (No septi system permitted H publ sawer�k
<br /> evallebio within 200 f"I T t} U <l
<br /> It alnatalleyon wql asrvs t Residence �Cornmerclai Cather::
<br /> at}i �Nilmtiei of living units: ,Dumber of bedrooms
<br /> k 1>1 it i Chirecter of 6011 to a apt of 3 feet.
<br /> „ ...: a .. Warer tabic depth }
<br /> 5EP71C TANK. ❑ TypelMig ' Capacity___._ No.'oropertments s '
<br /> Method of Dk +1 rY�ro t Nt 7s r v
<br /> PKGl'.TREATMENT PLT.r
<br /> I]is ante to nearest. well FoundaAon „-L Property Line
<br /> ,
<br /> LEACWING i INE No.;8'Length of dines �- — Q f Totel lengthJsiza
<br /> FILT1eR.9ED CI Distance to nearesr. WeI1QQ'`�� Foundation Property Line' t� a
<br /> ti.1 it 1 1"4tst f^.,;zrC
<br /> �Iifril,u� Namber iii;'cslpl+f '`w � ',
<br /> us 15kiPAGE PITS 0 Depth Size
<br /> r +r
<br /> Distance to realest Foundatwn " ' ^Propalty Line 3, +
<br /> DISPDSALi PONDS -a;
<br /> oe that I havo prepared this application and that Gia work will be done In accolcfanoe wRh San UoaquSra',tourtty ordtnencis 6tate laws arxl1 y
<br /> hereby. rNfy l v_ I � -„ e:.. ,.:,. � rt�q���cwMJ�I•!�ii��'�C��t9t�
<br /> n:&"end n guirtionn of.the San.loaquln Local Health DistrictIn
<br /> Home.owner..or.licartW'gags signoture.eeriNies,the following ,"I-cerdilr.that ln-the•perf0mtanee of the work for Oust cl1 t p+xrrilt b 4aled E Niall nett
<br /> I 11 +emploY'dny iN�o�In wo>t'nianner:ae to beadme subject to workn-k10 cornpensation Iowa of:Califomla',Contreetads hiring or aub•eontraetlnp atgnittlre l g;
<br /> ;lr l,, certiffea the follcwing''I earth that In the perforrnet4a of the work for which this permit Is issued i shall employ imrsante subject to workmen's eompehaa 4
<br /> tkx!}aw8 of CN1tomle
<br /> s e yTYiepPlfce call far�eR%requir Inspe�itlons Compile drawing on averseJt
<br /> �' :n
<br /> ,l lJ r_ tlw 3t t ' I �J ,/"✓�C/Z. l F_ Dat ", S°alt i` PI
<br /> �h
<br /> Signed ' _ __--
<br /> tC I f
<br /> /7 - Title: .'i t=�' '4ti 1L�Trrt IYi R - �<�1'„'
<br /> _ '�j
<br /> r It 4 .i DEPARTMENT USE ONLY 2 / l 4 Q f 4s yr
<br /> s
<br /> ` Application Acctpied by r � Date 1Arse (�
<br /> i i:.; ?- ani L
<br /> Ph or.Grout irnpec2ion by Dara Flnel Inspection by I
<br /> 77
<br /> Additional coinmenri ai
<br /> C] Stk:i8M7S1 '.0 Lodi 3e9-3B21 �; Manteca: 823-71D9 C]Tracy 8365386
<br /> Apppeent Return all copies to Environmental HeI PenM/Ssrvlces 1801E,Hezalton Ave., P.O Box 2009 Stk,CK j.
<br /> FEE AMOUNT DUE 'AMOUNT REMITTED CASH
<br /> RECK 9CENED 8Y DATE d?ERmn m
<br /> INFO
<br /> ' 1 +.FH 5171 IPEV.,IOIpI - � - -�.�•��y�' ��� �'�' i ! i
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