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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON. CA N94 <br /> Te***M 12051 *007111 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a <br /> -- (Convime In TrIPNcm) <br /> an0/a ia1M/M stere Mein tlea4EL IME tIPp1Cr <br /> Apps n is hrrimade r,the San Jo n Local <br /> su <br /> dneonmpaermct,with San Jopuin County Ordinance No.So to sows" <br /> osa8WHO.18621w sItnptaiMeBdof M sw Jaeele <br /> ! <br /> Local health District. <br /> t� <br /> _C�• �LZI_ Alm Q N N ae Cliff&'�'lAI 641' AIS C PIA i <br /> JOG Aedes <br /> pePmer's Name <br /> t 21LA..•`•`ee ��..�—iai �► Ir. /�0�. PhoneC"BS <br /> Centrwta I int/Jry 'n Q t:•.ADdi `ass (�. RfiI f/a ,`Icemes Ne.a903 s>Li Halt <br /> TYPE OF WELL/PUMP: N LL WELL REPLACEMENT ❑ DESTITUCTION ❑ f <br /> PUMP INSTALLATION 1.0 SYSTEM REPAIR ❑ OTHM O <br /> DISTANCE TO NEAREST: SEPTIC TANK /�.J SEWER LINES DISPOSAL FLO. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL —_ 07HO WELL PITSISUMPS��S.� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> ❑Industrial 19fOW^Bonom U Mentha Die.of WON Ea OM M YVaB Caalr9 <br /> IOAtr+nsati:IPrmvam ❑ Grawl Pack ❑Tracy Type of Cahhng .1 •ee I SPKWCmi ra 1 <br /> rlrPu_d..k__ n Other n DaKe Depth M Crrw1 SOW :� Tvpa d , <br /> _ Approx. Depth I I Eastern pylaw Sew Instaft M V l - �+ <br /> AAA I 1 MgaNan '/1 <br /> — <br /> ! Repta Wa. Oona L7 Type of Pump H.P1 Stave Win e Oar. <br /> Wall Destruction Ll Was Oiwneter Sea"Matarlw Itop 50'1 <br /> Depth Filer MOWW IBwow W) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR rADDITION( I DESTRUCTION 1 1A " Mtn 200IW) <br /> tad <br /> 8 pmlbac www le �� <br /> DrHBation will Serve: Residence_ ConerarcM— Other <br /> Number,of evin9 unite: _ Number of bedro(arta _ Waur table dsOrh <br /> Character of Boil to a depth of 3 teat -� <br /> SEPTIC TANK ❑ Type/Mfg CapsCPe No.Cor vw"rena 7D <br /> PKG.TREATMENT PLT. [I Method d OMPOaw <br /> Oapence to nearest: Wall Foundation Propene Lira-- . <br /> LEACHING LINE Ll No. 6 Length of WAS _— Told Wath/alae <br /> FILTER BED Ll Distance to rmoeresr: Wa11 Foutdatiam _ Ptoprh/Lia <br /> SEEPAGE PITS I I Depth Sim µember <br /> SUMPS t I Distance to nearer: Wall_ Foundation Properly Line <br /> DISPOSAL PONDS 11 ordelarmces,stag laws, and <br /> I hereby"I that I hove Prepared this application and that the work will be done in accordanca"'nth San Joaquin counh <br /> rules and regulations of the San JosI Local Health District. wak vrlmich this Is issued. <br /> 1 was not <br /> mw <br /> Hoo onar a panty licensed& signature certifies the following: "1 carnfy,that in its pedormalcs of <br /> the empty any person in such rnsrmrmer a to GetOnme erltrptt towaknman�•cornoarestbn laws of California."ConnaotOls hiMg or aub corttractimp wgnerum <br /> Canuffee the fokwng:"1 certify that in the performance o1 the work for which this permit is Issued,1 shah empty Persons avian toworkrtan's connpermw- <br /> uon laws of Cwilornia." <br /> The applicant must Cee for an requited <br /> J eQ1•�ineractions. Cpmplete dewing on <br /> everse side. <br /> ed -�C <br /> SignXC 7``/1 �TtAnn. TNN: +C? %e , Dmf <br /> VbA DEPARTMENT USE ONLY <br /> Date LL— Amp <br /> Application Accepted by <br /> �, <br /> Dal Final Inspection fA , ° t.• AaN �:. o <br /> Pi a Grout Impoctwn DY // <br /> Additional CpmrrmenH: <br /> I-) Sit, MF-6781 ❑ Lodi 3693621 ❑Mmtecs 823-7101 ❑ Tracy <br /> 1 Applicant Return vel Copies to: Environmental Health Permit/Se iw 1801 E. Haawlon Ave.. P.O. Bos 2006. Sri.. CA85201 ^,�1 <br /> FEE AMOUNT DUE AMOUNT P"I CASH RECEIVED eY DATE PERMIT NO. <br /> . t+ua utv . /OS 00 2' <br />