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y" C <br /> �,k`* � -7 <br /> APPLICATION FOR PERMIT y <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> 1601 E. HAZEI.TON AVE., STOCKTON, CA 4 <br /> Telephone =9! 486-6'781 <br /> PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED k <br /> (Cam +ole in Triplicate) <br /> Al lic,tian Is hereby mTW 81010110111111011 Is <br /> ad,'to"'Son Jo�uln Laces Health District for a PwMit to constrw andlor Install the work herein dm~. S <br /> n,arSe in cvmpliarxx with San loegUPn County Ordinence No.649 for aewagrt or Na.1882 tot welt/pump and the Rulas end Raguloakm r cc, <br /> Local Herm,Drsfr'ct. nr a € <br /> PM <br /> Akja CRY LaSIke <br /> ' , <br /> nob Address 't, <br /> `, `:.,,Pltarie r n y <br /> Owner's Name AddreSa <br /> Contracts Address License No. -.-,Pe" <br /> TYPE Of WELL MMP' NEW WELL ❑ WELL REPLACEMENT ❑ DFSTRUCTIo <br /> C: SYSTEM REPAIR C OTHER 0 <br /> PUMP INSTALLATION ❑ " <br /> DIISTANCE'TO NEAREST' SEPTIC TANK �_ SEWER'LINES., .= D <br /> PROP'LINE <br /> _ e. 4 <br /> DISPOSAL FL _ <br /> --.FOUNDATION' AGRICULTURE WELL— OTHER. <br /> WELL PITS/sumps <br /> tia7L�Nf)I O'ISE TYPE OF WELL P4tr3BLEM AREA CONSTRUCTION 5PECIFICATiONS <br /> t "1tttlt:sirisl n Open Bottom C]•Marttaca Dia.of Weft Excevatian Dia.of Well Casing :} ; <br /> L; <br />+^ [7 t?omeet`rrlPrl+ratt 0 Gravel Pack 0 Trecv. Type of Card �I <br /> ' <br /> T of Groin <br /> #J Public E7 other 0Welts" Depth of Groin Seal Ypa <br /> Cl Irrlpation —;,:4pprex. Depth 13 Eastam Surface Seal Indtelled by <br /> R"0,WO.04 Dona a Type of PUMP' Hip:— state 1N _ .---- - 5 b € <br /> Well Desthiation `Ntfi 8""ng Materiel flop SO'i ` k <br /> . Depth ! '` Filler MatwW IBelaw68'1 <br /> RIC: NEW INSTALLATION❑ REPAIR/ADDITION LI' DESTRUCTION L1 IR;tsaptiC sY�m If public sewer is, <br /> s E Of 58PTiG WO available wkhk12011 feet i� v <br /> a Installation Residence Commercial.— other <br /> mber Of ifvEnQ units <br /> Number of bokooma <br /> Nu <br /> + Water table depth L <br /> f Character of soil to a dspth of 3 4 ', <br /> SEPTIC TANK ❑. TyM% Capae" No.Comps► <br /> urvents <br /> pal <br /> 4 PKG1 TREATMENT PLT:❑ Method of Disposal <br /> Disdmde to rarest: Wap -- sttotr_.». - Property Line ' <br /> LEACHING LEN$ 0 No.a Length of fines o /sire <br /> FILTER 6ED 0 Distance to nearest: Well Foundation-. <br /> SEEPAGE PITS Cl Depth. 5L <br /> Number <br /> SUMPS 7 Distertcd to rroereat: Weft. — foundation Property Line _. <br /> DISPOSAL PONDS L 1 <br /> '- I herehy txrrtlfy that I hers prepared this epplltallon and that the work will be done In accordance with San Joequhn courtly ordinanoea,stets laws,and <br /> r rules and Mgumd mrs of the ran Joegvin Locel Mtahh District. <br /> Home owner or licensed aganes signature(a rifles the fok"ving.'h 08,Wy that in the performance of the wank for which this pemdt fs.Issued.I"I not <br /> employ any pensotn M such manner so to become subject to workman's motion laws Of CoIlkwnie."CormecWs hiring or sub-contracliltg signaturecertl}ita iiia fallorAng:"I cerft that In the perlortnanca of the Work fa which this poll*h WOW,#Shan employ Altrsonkn; <br /> a subject to waran'a flortnpsnaa <br /> ti)n laws of Callfornis." <br /> The applicant for ail rot4u . Complete drewkng on reverie sift. <br /> k!ne <br /> Yk TMs:�_.Lei� Dalt: <br /> ^FOR VER ptMENT USE ONLY <br /> APFSVcation Amepted by ... Date—/, /— Arta <br /> Dalt '�r1 by <br /> i"t clr G-•nut In+Fpectlon tri r Final 1 Datta . <br /> ,vidwonm Cumnvmta: <br /> tk M396781 C7 Lodi 3W3821 © Msmeea 823.7104 0 Tracy 835-SM �a <br /> nprllcant- Ran',-n all copies roc Environmental Hearth Paln*/Sarvkros 100 E. Ha:dton Are., P.O. Box 1009,Stk.,CA 9=1 x.a: <br /> AMOUNT OU[ AMOUNT RE Cl-Ar-S; RECEM-0 By DATE PERMIT'NO. <br /> INrU S �' <br />