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a APPLICATION -OR PERMIT
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> t' 1601 E. HAZELTON AVE., STOCKTON, CA
<br /> ` Telephorle (209) 466-67,91
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> ^— (Complete in Tfiplicate)
<br /> Application is herob�made to It-.S-,n Joaquin Local Health District for a pe:mit to construct and/of intrall t:w work herein described.This application is
<br /> made in.ornpiian Je with San Joaquin County ordinance No.549 fo•sewage or No.1962 for well/pump and the Rules and RdgulotiaA of the San Joaquin
<br /> Loral Health District.
<br /> v '
<br /> Job Address _ o_S p _-`�'-r 'u- Ciry. �t__-Lot Sue --- PM
<br /> /�1L0! / VCL C.f-_ ._.._ ! t�''i 1__E__LetlG-_.O ►J ne 1Z '0 7`� LI
<br /> Owner's Name Address Pho
<br /> s�f ... ,,
<br /> Contract,/�ct!ol�_ ,A✓___ 4ddicss F�_�'c't��&-------•-l.icc,; 'Noy7:s? S.-ffione�s4�T t�
<br /> TYPE OF��lrEILfPUMP; NESV CJELt. WELL REPLACEMENT I DESTRUCTION i�
<br /> ___.._._.- __._-
<br /> PUMP d.'1 ALLATIONX SYSTC%1 REPAIR (1 OTHER L',
<br /> -
<br /> St OISTAN F TO NEAR_ST: SEP-hr TANK -_ ___-._ SEWER LINES
<br /> OISPOSAI F.D._ PROP.LINE
<br /> -- _ rOUNitATON __ AGRICULTURE WELL OTHER WELL___-_ PITS/SUMPS v
<br /> ' -INTE OED it PE OF WELL PROBLEM AREA CO_NST_'i_UCT17N SPECIFICATIONS
<br /> G Industrial- I_;Open 3ottom `6lnmxa Dra.of Well E�cavat,n _,n,.__ Dia.of WeK Canktg
<br /> .e rpo tic/Private Gravel Pack ,' Tracy Type of Casing-�'✓�= ___. _.:��--- SpeeNkations
<br /> #, - ;�Pubti i i Other i Arita Dettth of Gretit Seal _1�1C_._-___ Type d GRxtt
<br /> .� L Irrig n •�Yt)-.Appro■ Depth Eastern Eastern Surface Seal In stallby .Cts f� hGr_� rs._____..---- (A
<br /> t •-'`` Repair Wor4 Done fJ Type of Pump .5�� ----- H.P. ___.--Z_..____. _. Stet,Work Done
<br /> Well Destruction rl Well Diameter -. Seali,lg Material(top 501
<br /> ��' ' Depth__-...---- Filler Material(Below 501
<br /> - TYPE GF SEPTIC WORK* NEN INSTALLA J.11:- REPAIRi�.;JDITION I. DLSTRUCTION -a'No able c within
<br /> nm permitted if PuAc sewer K CN
<br /> a�ailaWe wnthm 200 feet.) Y,
<br /> �. Installstu,n will ac-ver itesidonce __.. Commr!reiel ._ 01nar .-.. ..._.......
<br /> Numt>,u of living units: ____ Nurnbot of tYdmoms .. _._
<br /> Wath.table depth
<br /> Charadoil e•of sto a depth of 3 feet: .. _..
<br /> .,,t. Capacity. No. Compartment, `
<br /> SEPTIC TANK Cl TypeeMfy
<br /> PKG.TR;fATMENT PL f.fl Method of Disposal
<br /> `t, Dtsr nice to nearht: Well- _._ Fo nidation___-_._._ Property Line.-__--- �
<br /> -
<br /> �llines -- `
<br /> ,.5. LEACHI G LINF_--.' l 1 No. 1%Long of Total -_----
<br /> '4s f..: Distance to nearest \VMI _ -- Foundation ___. �_ Property Line.-_-,
<br /> 'yrs. FILTER QED -_
<br /> ` .Stile_ -- -- - Number
<br /> SEEPAGE PITS (' Depth ---- - -
<br /> SUM.•S I 1 Distance to nearest F xrndetion .- -_ Property Late
<br /> DISPOSAL PONDS :1
<br /> I hereby certify that I have prepare!C - opplicanon and that the work will Lie done in accordance with San Joaqut.,county o+drrtarxes,sate law:.and
<br /> rides and regulatrt.ns of the San Joaquin Local Health District.
<br /> Name owner or licensed agent's pgruiture rertdres the following:"I ce'tily that in rtte pedormaace or ilia work for wh�h this permit n issued.1 shall nor
<br /> -contractisign
<br /> ,ploy any person in such bhran
<br /> h manner as to '•coma sublac'to wo .n 's comrw,Asahon laws of C [i'on�a."Conn,:ctri�compm
<br /> ehse
<br /> 'r certifies the following:"I certify that in tho perinimance of the work for which this peernil is issued.:s',all employ poro,�rtasubi"ta to dkman
<br /> _ tion la•+vs of California."
<br /> The appiic-ant must,eall foe all requurd� inspections. Complete drawu,q or,revarse side.
<br /> ' Data: 5:
<br /> ai G'.,t/ /� Title:
<br /> Sip nt•d X. .rs��......_.__-...___.-_._.__ .
<br /> DEPARTMENT USE ONLY At"
<br /> Dale. =_L
<br /> -_ J.=a, Ar ---i -
<br /> App!iratior,,,Acr.acaod by -"�h�'�^^,_ •.�..... -
<br /> 1 inel Inspection _ Dare
<br /> �_.._
<br /> Pit oe GroL•�npection by 1� C� =- - Cate - - - -
<br /> k1clitio al Comments: -- - `- --
<br /> G Stk 0-6731 C Lodi :39.3921 L.,"Aameu 823-7104 L)Tracy 8355385
<br /> 46
<br /> Applicant- Return all copies to:Environmental Health Permit/Services 1661 E. Haaenon Ave., P.O. Box 2009,Stk.,CO.95201 (1,
<br /> i FEF
<br /> �,5s tt„•t, lily , Ir (7 ,D<V P� L b -��G It _REC..E-
<br /> IVE-C_PY•- S=DUAT-E? ryPE-R
<br /> MITd-
<br /> NO
<br /> AMOUNT DUE AMOUNt REMITTED CASH
<br /> INFO 6
<br /> lSa,-, .
<br />
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