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r - _ yq���yIyrryyyy����1 , <br /> f <br /> APPLICATION FOR PERMIT <br /> 8AN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1901 E. HAZELTON AVE., STOCKTON, CA L*6t- <br /> PERMIT <br /> t�3f f3 <br /> TeliViorw (209)1994751 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i -li`nri <br /> (CompMN in Trip9nn) <br /> AODkntion•he"melte to the San Joaquin Loth Reath 01tl lar■ptftep4 a co snret aR0/ep itmE h wep Title spokodw te t <br /> meoa in compliance with San Joaquin County Ordinann No.50 for aoteaga a No.IOU fe wain/putty and•tat Rule wed R.pulalions of pa San Joaquin <br /> Local Health District. T <br /> Job Address A/ N.A,(/A/ )ed CaY ACANOo Lep sies fall . <br /> owrnels N,rneC�NA�II.l f. PnS Acidns j'?3 W fL.f Iw�1 Pines 1 `. <br /> Cmtfacto,60/EJ SC^c-17AX 4 AaereuPp '60X 'IG7 �.e. !.0 Licari No.3ZiuG Phare 3G /o� <br /> R TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O <br /> f} PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER <br /> ^ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROF. LINE <br /> 1 <br /> t FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECP- AT10N3 ill <br /> _ ❑ Indushial ❑ Open Bonom ❑MmwA 61 of'ate EicavaEion Dia.of Well Cskelf \ <br /> ❑ Domastic/Private ❑ Gravel Pack ❑Tracy Typo of Caayg__ SpodMatbrs -11 <br /> 1.1 Public fl Other Fl Data Depth of Grout SW Typo of Orad_ _ V <br /> 1 1 Irrigation _Approx. Depth I I Enters Surface SW Installed by <br /> Repair Work Dom 0 Type of Pump H.P. Ssea WtKa 0"— <br /> Wall <br /> este_WM Destruction O Web Dianater Sealaq Manana(top Sff) <br /> FF Depth Filter Materia(Below 500) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 1 DESTRUCTION 1 I IN*asptk.eaten par ~4 public sewer is <br /> owaeDfa wohyt 200 hat.) <br /> httataron win serve: Residence_ Commercial__ Other <br /> Number of living unity: _ Number of bedroono <br /> ' Chetwhy,of soil to a depth of 3 feet: a. a�e Wast table depth <br /> SEPTIC TANK Ll Type/Mfg 14 ty-I 1 CepocRv-jbV.W No.C«,gah,s„ts <br /> PKG.TREATMENT PLL Ll Method of Disposal <br /> Distance to nearest: WON Foundation Property Lysat�_ <br /> 'T^— <br /> LEACHING (INE � No. 6 length of awes Tata tettpth/ � . <br /> FILTER BED LI Distance to nasi WM Founuetion Property Lis <br /> SEEPAGE PITS 1 I Depth 1' <br /> a sun-73 f mut tar _ <br /> SUMPS I I Datance to nares Well Foundation <br /> Propene Les <br /> DISPOSAL PONDS Il <br /> 1 hereby certify that I have prepared this application and that ted work will he done in accordance with San Joaquin county ordeurlcea,state lame, and <br /> rules and regulatlom of tna San JoaWnl Local Heath Oistrict. <br /> Home owner c,licensed agent's signature certifies the following: "I cardfy that in the performance of the wed for which this permit la fsued.I shed not <br /> amplov any prion in such manner as to become sublect to workman's compenaahon Laws of Ca onve."ContractoYs h ring or sub cOntractirg signature <br /> Cartiftes the following:"I certify that in the Performance of the work for which this permit is iaalred.I shse employ peraom subject to worknisn s cornpans- <br /> tion laws of California" ) <br /> The appktan Nun M raguie peetlora. Conte drawing on teyarae ads. <br /> Signed i•' •' Title: !Ld R.+/G1.. Oate: I �� <br /> FOR DEPARTMENT USE ONLY 'f <br /> Application Accirpted by �_ Date `' _ Ares <br /> PI a Groat InspecT,o __ __ Date Final Inspection by Das <br /> Additional Comments: _ /y-tr <br /> ❑ Sri 46e-6781 C: Lodi 3693621 . Manteca 823.7104 O Trscy 8356385 <br /> Applicant Saturn all ,-1p.,to: Envvonmennl Heahh Patmt/Services 1601 E. Hasaton Ave„ P.O. Boa 7009, Sri., CA 95201 <br /> ItiiO Ir AMOUrNI DUE AMOUNT REMITTED K H RECEIVED BY DATE F(- I�eFRE17 1a0 <br /> . fed ll}r IRfV Z -VB VV <br /> R IbM <br />