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w <br /> ' APPLICATION FOR PERMIT <br /> SAN JOAQtUIN LOCAL HEALTH DISTRICT <br /> ;a <br /> 1601 E. HAZELTON AVE., STOCKTON. CA <br /> t "y Telephone 12091466-M— ;16 T-3 o <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> tJ <br /> (Complete in Triplicate! <br /> Application is haraby mode to the San Joaquin Local Health District for o pem%h to construct and/or instar the work heroin daaefibed.This apptiration is <br /> made in compkanca with San.lomuin Counry Ordinance No.549 for tewaga or No.IOU for wag/pump and the Rules and Regulations of ttne San Joaquin <br /> Fs Local Health D;VW41t. <br /> I c 1C(�O/r <br /> Joh Ad*m o r H C6ry Lot Sue PM <br /> Owners Name Ic i Addr. I�.S n a D-1, Phar <br /> I ' �'"anTjtA 9Y�3$ <br /> Contraclar SAICJ tk. 9S Address gLk3 ZELL s7ty r LfcemNo.-Y(05!3 y ..Phonal /s <br /> TYPE OF WELL(PUMPe. NEW WELL O WELL REPLACEMENT 0 DESTRUCTION O <br /> 9 SOIL- Bt7r•r✓fy <br /> 4 c PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER 13k <br /> DISTANCE TO NEAREST: $6PVC TANK SEWER LINES DISPOSAL FLO. PROP.LINE <br /> i <br /> (_J FOUNDATION AGRICULTURE WELL OTHER WELL FITSISUMPS <br /> I INTENDED USE TYPE OF WELL PAOSLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial ❑Opsa 8ottem Q Manteca Dia.of Wad Excavation rr. Dia.of Won Casing <br /> #,a O Domestic/Private Cl fin"Pack ❑Tracy TYPO of Ca*Kl - — Spedrttatiord <br /> l <br /> O Pubgs f3 Qtltor SprlpJa Delta Depth of Grout Salt - Typo o1 Grout f <br /> D lrrippityiatnJ•�L�S t i 22 a.Depth O Emalem Surfara Seal In zww by ^� <br /> fl�ipair W �Otte » Type of Purnp H.P. State Work Done <br /> f WON DesYrmlmi ❑ Wee-Dlarnetor S"lin9 MSWW atop W) <br /> ` Depth Filar Material(Bakm ST) <br /> TYPE OF SEK WORK: .NEIN INSTALLATION O REPAIRIADDITION O DESTRUCTION O juaOreptiC system PMA ad if public sewer 6s <br /> aYaiabde within 2p feat.t <br /> InstakudonVA Rmzkwm— Comnercial— Othw <br /> Nu-.1w of living Number of I:vdw—,m — <br /> Chane w of teal to a of 3 frost Water nble depth <br /> SEPTIC TANK f] Mfg Capaaly No.ComPwtmervis <br /> t:7 PKG.TREATMENT PLT.O Method of Deposal <br /> Oiatancn retest: wig Fourdetion _Property Line <br /> t <br /> LEACHING LINE -..' ❑ 'f'lO-�Zi.Lsn9eh of 6 Total WngthlsUe . <br /> FILTER BED © .Distaimm'10 _ ace all Fou dstion- Property line <br /> Dwo <br /> SEEPAGE PIM ❑', Siu Nutstbmr <br /> ksi SUMPS 0 to rrareat: Waft tion fst perry Lime <br /> DISPOSAL PONDS ❑ <br /> I hereby cortdY that I to propend tftie applicapon aryl tart the wait wN b:Aare in s000+dand with Sart Joaquin county ordiruncee,sato laws.and <br /> t;3 rules and" MS MUfir San Joaquin Losal 14061 Oi.erict. <br /> Horror owner a i www epWa sipu tt m cordrus tM foftt*mq:'9 csrtify that in the Womtwm of the work for w0hich alis pwn*in W000d.I"not <br /> —play any t,eredn In such Miff w as to beoome.ubjaet to workman's ottrrvormation laws of CWfwrra."Ci-HracWs hiring or orb aoretraeting signature <br /> ootdrreo the foil wirq:'7 emov tlfot)d�e ormAnca of the work for,%16th O%is permit Is issued.I s!W employ pirsaty aabjwt to wor9cman'a wmpansa. <br /> �� tion sews os <br /> The t tar for ar ngtdsud Complete drawing on t vww . <br /> l Signed � �yl Tide: • <br /> �sy FOR DEPARTMENT USE ONLY <br /> Appl6udon AcomrbWy — Date Ares <br /> Pit or Grout Impaction by.. Date FLtal Inspection by Date <br /> Add6tkmW Convener: <br /> E3 Stk 411111411M O Ludt 3118-ml ❑Manteca M7104 0 Tracy <br /> ARpUwa•Return ad Copies to:Environmental Hearth ParMlSomm 16DI E.Hasten Ave.,P.O.Box x0(18,Stk.,CA 9=1 <br /> F•A <br /> ff:E AMOUNT am AMOUNT It ED RECEIVED G DATE PERMIT'"O. - <br /> mm CASH <br /> art.d+117a laev v+rar <br /> IN 14-U <br />