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`PERMIT �. <br />AQP4ICATION EOR DRICT <br />�DAQUIN-tOC - HES�oCKTISTON, CA <br />SAN E� i ON AVE , �/8i <br />1601 E. HAZE I _ �209I 466- DATE ISSUED <br />YEAR FROM This app►pone <br />kation is <br />l PERMIT EXPIRES in Tripyjcatel herein desc <br />ribed. <br />(COmpMete Re ul+tions of the San Joa4uin <br />ermh t° construct nd/mp and the Rules and 9 <br />District for a P,. or No. 1862 for wall/ <br />San Joaquin Local Health for sewage .7 PM <br />Ordinance No. I <br />made to the Sar County. Lot Size <br />APplication is hereby Joaquin <br />in compliance,with San City <br />made / Phone <br />Local Health prstrict.r c <br />Address J Address _ phone i <br />,fob A � <br />DESTR <br />Owner's Name License No. CEMENT ❑ OTHER ❑ UCTION ❑ <br />WELL REPLA ❑ P. LINE r <br />NEW WELL ❑ SYSTEM REPAIR FLD.� PRO <br />Contractor's <br />Name 3plSpOSAL PITS�S�MPS <br />WELLlPUMP' fI,'ISTALiATION ❑ L11VE5 OT4iER WELLS <br />TYPE OF PUMP SEWER <br />AGRICULTURE WELL TIONS <br />TO NEAREST: SEPTIC TANK l TRUCTION SPEC1FlCA Dia,rof Well Casing <br />DISTANCE FOUNDATION C( , <br />pROBLfcM AREA Spgcificat, <br />TYPE OF WELL 0 Man Dions <br />a. of Well Excavation Ty It of Grout ; <br />INTENDED USE ❑Open Bottom Type of Casing <br />❑ Tracy l <br />❑ Industrial ❑ Gravel Pack Depth of Grout Seal <br />` asticlPrivate ❑Delta L_ <br />y ❑ Dom. ❑ other Surface_Sea1_Installed bState Work Done <br />❑ Eastern � I t <br />❑ public ppr°x. Depth H'p <br />N1 ❑ Irrigation ❑ <br />Type of Pump _/Sealing Material )top 50.1 ublic sewer is <br />Repair Work Done tic system permitted if P <br />Well Diameter ,f_iller. Material [Below i ❑ {No-seP <br />Well Destruction ❑ Depth ❑ DESYVCYIQN ava++fable within 200 feet-) <br />` INSTALLATION � REPAI R ppfSlON _ f <br />TY <br />PE OF SEPTIC WORK: NEW \ Other <br />i Residence r �O!!!niercia� Water table depth i <br />Installation will serve: Number of "Ll 'ms No. Compartments <br />units: ' Capacity <br />r Number of living t of 3 feet: " » Method of Disposal <br />�� <br />Character of soil to a dip �'Type1Mfg y property Line <br />SEPTIC TANK Well �"r4 /'XFoundation �J +.� <br />4 TREATMENT PLT- ❑-/�"7"T <br />PKG. Distance to nearest,.-,, length/size <br />„• Total fang! <br />r _ prop8rty Line — <br />Length oliries j <br />�No. & Lengf Well Foundation <br />' LEACHING LINE ❑ Distance `to nearest: <br />1 FILTER SED j4� d Number <br />Size 3 , . t7 Property Line <br />DePi . We11 _ -f1- foundation <br />I SEEPAGE PITS ordinances, state lay <br />1 ❑ Distance to nearest: + i <br />L SUMPS A ! ' <br />i ❑ �� rmit is issued, 1 1 <br />DISPOSAL PONDS this application and that the work will be done in accord once <br />with <br />f he wok for San 1which th'Isope subcontracting s <br />certify that 1 have prepared that,"' the performance Contractor's hiring <br />f 1 hereby I certifysons subject to workman's co <br />ensation laws of California!'Ca1'�f; hal'I'empl0Y P <br />nature certifies the foNowing: ermit is issued. <br />rules; regulations of the San Joaquin Local Health Distnc .Y <br />i Home owner or licensed agent's sig P <br />person in such manner as to become subject' <br />oft a work for wh cOl ch this•p <br />i employ any pe I certify that in the pe <br />certifies the following: " Complete drawing on' teverse side. Date: <br />I tion laws of California." uir inspections. Comp P <br />The applicant ust call for all req Title: <br />If <br />AI <br />1 ed FOR pEPAR MENT USE ONLY �( <br />Signed � 1U ✓ . r' Q - Area <br />rJ Date pate �1 <br />�j^ �rb Final 'Inspection by 4,p <br />AppAcation Accepted by pate <br />Olt <br />or Grout Inspection by 638b <br />❑ Tracy 835- Stk., CA 95201 ! , <br />r - 1❑ Manteca 823-7104 P.O. Box 2009,. <br />Additional Comments O Lodi 1601 E. Hazelton.Ave., i <br />❑ Stk 466-6781 copies to; Environmental Health PermitlServices PERMIT NO. <br />Applicant - Return all cop DATE <br />j CK # RECEIVED BY f <br />AMOUNT REMITTED CASH ' S -13 5 e <br />FEE AMOUNT DUE.. r <br />INFO <br />fix 13-241RV. 10193) S a <br />