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APPLICATIQN FOR PERMIT <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.. STOCKTON, CA <br /> Telephone (3091 4666761 <br /> PERMIT EXPIRES 1 YEAR FROM.pATE ISSUED <br /> (Complete in Triplicate <br /> is <br /> Application is hereby made to the San Joaquin Local Health District for a nermd to construct am/or install the wch hamin deathbed.This application <br /> made In compliance with San Joaquin County Ordinance No.549 for 4alwage or No. 1962 for wou,ump and the Rules and Regulations of the San Joaquin <br /> Local Health Di9t,ct. ' <br /> Job Address .., T Gry_S:ic'C-- Lot aim/1_Sf.�2t� PM� <br /> /�iJ'i•.--_ __— <br /> Owner's Name r%'i'�'�� i C N�— Address —..t.'� Phone <br /> r ' Phan 'SCE ' L!' <br /> Contractor's Nama �.��le / & ��c/&sn.se No., _ ��..�.—�•�— <br /> TYPE OF WELL/PM <br /> UP: NEW WELL G WELL REPLACEMENT DESTRUCTION G <br /> PUMP INSTALLATION C SYSTEM REPAIR C7, <br /> OTHER ❑ <br /> UISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - . DISPOSAL FCO._ PROP.LINE —_ <br /> FOUNDATION AGRICULTURE WELL,___OTHER WELL__PITSISUMFS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS e <br /> On.of Wan Cakq A <br /> ❑Industrial LI Open BORom u Manteca Dia.of­Wel cavalion Specifications <br /> C Domestic/Private C' Gravel Pack L:Tracy Type of Casing_ I <br /> 7 Public <br /> I Other C Delta Depth Of Grout Seel Type of Gfout l J <br /> l <br /> litigation _Jtppras. Depth ❑ Eastern Surface Seal Installed by_ <br /> Repair Work Dom C Ty.+of Pump <br /> H.P._____ Stitt,Work Dan T <br /> Well Destruction L N dl Dlemeter Sealiag Material Ing 501 <br /> t•eDth Filler Material IBenw W1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION - REPAIAfADD1110N . DESTRUCTION G avae�e with�2000ffast.) it Wdk sewer h <br /> Installation will aerie: Residence- Canmerclal other _- _ �'t r/",/, 1 �a f/�1// '.% '^`r /-� l� <br /> / 1 <br /> NYItTbor of living units:= Number of bedrmma_.'_-__- -Water table,depth�a.ET • <br /> Charsctaf of acs to a depth of 3 feet-�(�/ ---`-- -------- No.Cornpertm is <br /> SEPTIC TANK C Type/Mfg Capacity._--- <br /> PKG. TREATMENT PLT. Method of Dleposal -- <br /> Omm�to menu: We".---- Foundanorl_.___ Property Lin <br /> LEACHING LINE No.a Length of limas _ _ - - ------ Total length/5114_ --_--- —_ <br /> FILTER BED C Distance to manst: Wan Famdahon',_ Property Lim <br /> SEEPAGE PITS -_ Depth �Sk4_ .' .-'=•-_ _ Number - <br /> SUMPS <br /> C. Distinct,to merest WN' ._ Foundation. .__ PropeM Um <br /> DISPOSAL PONDS G <br /> 1 hnebY Lenity that I have prepared this application cn and that the work will M.dOt1n accordaxa with San Joaquin county ordinances.state lewa,am <br /> ruki and regulations of the San Joaquin Local Health District. halt n Issued.I amn not <br /> Honve Owner or licensed agent's signature ca lfles the following. "1<ertdv that in the RHmtnanca of the wove for which this pershim f <br /> employ any person In such rmnner as to befdrrn wbpcl tv wuhmana uvnpensetldn lawn of California."Cnntractp era cab hillng 0r1 roDwnkrtan'sncompansa <br /> can ties the following:-1 cenity that in the Indonnante of the work for wdwh'tos Period s nAu W.I shall 9mpl0Y pe <br /> tion lawn of Cali1ani4." <br /> The appl�ca r at call for all squired Insperttbynss..Complete drewing on.rove <br /> 'ry`�---kms--Cly Titer: � -- Oen: 7 <br /> Signed R ��n % ___.-. <br /> Fop`/OEP/IR'Mlhrr USE ONLY �/ <br /> ApplknlOn Accepted by 1 ` ---+-=/CJ__._.... - Data.. - Amp <br /> Data <br /> Ph or Grout Inspection by Date_, -- . F,ml,napecfV,by <br /> Additnnal Comments: \c.J .�i�t. r ;� 'c.?l�. Ic .___ !- •_�-__-`-�. f�--_-- <br /> C: Stk >Lodi 369-3621 '.7 Mentor Sup-740405 <br /> -. Tmcv N5t1M <br /> Applicantnt- Return all copies to:Environmental Haahh Permits Services 4601'E; Haronon Ave., P.O. Baa 2009. S[k., G 95201 <br /> K F RFCEIYED BY DATE <br /> PERMIT NO <br /> FEE pk1DVNT CULJAIAO�lTaEMITTFD Cp511, --_ <br /> NFO — <br /> . Fe 1)N la<V 100� <br /> le 1,d LA <br />