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r•• <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to rho San Joagtnn Local Health District for a permit to construct and/or install ilii.work herem destri <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and r� <br /> Local Health District. fwd.This application is <br /> _ egulatrorts of the Sart Jaaqum <br /> Jab Address !A1 <br /> a G r ' T. r �t ' <br /> City Lot Sire C Mir PM <br /> Owner's Name �r, z,.,� I <br /> r Address `I'.`3-1"C 'e.1,Lcv,ij r Vve i-S z <br /> qi =t LkI Qe, c. r Phone <br /> Cantrac[ar/.►aiau•7� �,u e.' , 4 F. C i :cr <br /> _ dee-7•.Address_Y r � j-�it <br /> TYPE OF WELLlPUMP: °�' License No. a• C <br /> NEW WELL a Phone`/r7 r:L4:.^`913,j I <br /> PUMP INSTALLATION ❑ WELL REPLACEMENT 15 DESTRUCTION ❑ <br /> DISTANCE TO NEAREST' SEPTIC TANK SYSTEM REPAIR ❑ OTHER (� <br /> —•�._. SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> INTENDED USE OTHER WELL or. ITS/SUMPS <br /> �`"` TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS <br /> Ci Industrial Q Open 8.U. <br /> u Manteca Dia.of Well Excavatipn <br /> y� <br /> Domestic/Private Gravel Parts pia,of WON Casing <br /> Cl Public Tracy Type of Casing r1 e <br /> ❑ Other SPecificatiiorts <br /> I I Irrigation 1 ❑ Delta Depth of Grour Seat -� <br /> Z�Approx. Depth I 1 Eastern Surface Seal Instated 1»j Tye of Grovrl <br /> Repmr Work Done U Type of Pump H.P. <br /> Well l:tistiuctron Cl W64Dianterar rlcltr.F, State Work Dong <br /> ._. Sealing Material(top 501 rt <br /> Depth _ Filler Matnal fB1y4XV 5011 <br /> TYPE OF SEPTIC i/VORK: NEW INSTALLATION 1 I REPAIR/AODIT[ON I I DESTRUCT[ON I 1 [No sept <br /> li'W'"atian will save; avaitabie tystam permitted if pubye www is <br /> Residence, Commercial_ Other within 2100 feat.l <br /> Number of living units: Number of bedrooms <br /> _. Character of sail to A depth of 3 foes <br /> SEPTIC TANK ❑ Type/Mfg Water t3W depth <br /> PKG. TREATMENT PLT.Q �`—�" <br /> Capacrry�� No.CvrtKya+an,enz: <br /> Distance to nearest; WellMethod of Disposal <br /> Fotmdatian--� PropenY Line <br /> LEACHING LINE L No. &L&Vth of knee <br /> FILTER BED Q Distance to rloareat: Total Wgrh/size <br /> Wed Founda>imn <br /> P►ofWtY Line <br /> SEEPAGE PITS <br /> E I Depth <br /> SUMPS <br /> Ll Distance to rleararst: way ithrrtbar <br /> DISPOSAL PONDS I--]' Fotrndatitm Propgrty Late y, <br /> I homby certify that l have p"Warea 601d that ulm -M <br /> this <br /> rules and"Dations of the San,IoapJi"LOW llralth oft=. ' widl be dors;n-4-da r"with San,toRKM <br /> er <br /> Hoo ownor"I"d +n Y .:tato 18wa,and <br /> employ anti person <br /> in lrJChn".0, <br /> 6¢tet man�fV that in tM periortnartq of ft wont for hcat"ri'm the following:"I eta*Vpwforw his of the work for which this bon l�of Carilomis...Con h+�Ofpwrm atacrd,I:slay not <br /> tion taws of Cjfp�•• ,}- (&nils rs ynu id.1 OW whplogy a > aCtillg ei0mtturs <br /> applw•a••. ` <br /> _..: __...., .. ...Tho. a� ---. _...... .... .. .. --- .. _...... _..... _ Por�otla raabla+et to.wgrlrenerl'a comPer�___ ...... <br /> r 0111 Complete drawtrtp an rrvwys side. <br /> Signed X �i�• + S <br /> =rile Date: 3-l- 40 <br /> , . ser <br /> Z . <br /> '; L, rt cC �tl� .OR DIEi=A�y <br /> MM>ENT USE ONLY <br /> Appilkatfan Accepted by <br /> Pit or Grout hlspeetion by- Date Arai <br /> Data <br /> —�—�Fidel k%pecsiwt by Dam <br /> Addttfoesel commanw: <br /> ❑ Stk 496 4781 to:IO Lodipi363521 C3i a23-7104-710q C3Trary 696.6ilag <br /> �pPaCartt•IRWwn ad casa EnvircKxtlsnty Hetddl Ptd/ <br /> Serve" 1601 E.Ham Abs.. P.O.Bos 2IX@,Stk.,CA SM <br /> iNFO AM WNT DUE Ahet)UWT REWiTTED <br /> CASH RECEIVED By OATS <br /> - tlt 03.,U 4111110F.t r�et raw <br /> 111141 - - <br />