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AN <br /> APPLICAT1614 fOR PERMIT FZ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 111.466-678.1 <br /> PERMIT EXPIAN't., 0DAVE4MIED , <br /> Application ls.hereoy prodsto the Sate.�?"UW,f'laalfh Di VI"for 4W-00,to contract arWor�the work hw*t,desu bed. This application is <br /> made in compEiancat tar San Jaaqui[t Qrdinanc&Na 5 lVo. 1012 far mal pun the Rules and Rs�#rlatIons of the San'Joaquin <br /> Local Health Dlstrict." <br /> Job Address, Q Cit <br /> +' r <br /> y tom'lira PM <br /> owner's Nano A � /��^'""`7� '� _ Address i-06- 19 Phonel � <br /> Contractor AlfdtCSS - License nab Phane5�6 <br /> TYEE.IN.1+IE�.IPt#Mf�. ::...,. Q. ' 1�GLi.1EP1�CrI�NT. � RESTRIJCTION ❑ <br /> — PUMP INSTALI;iTION:© SYSTEM REPAIR �'. OTHER ❑ <br /> DISTANCE TO NEAREST: SEP (C tllNK SEWER LINES <br /> OS At LD. PROP. LINE <br /> .w y... .. AGT UL1• ' - PITS b MixS" <br /> INTENDED USE TY OF WEkL PROBE A CONST*JC1<ION S"PICATH IS <br /> ❑ Industrial 110+1 Bottom. ❑Manteca Did. of WeB>:xcavatiorr Dia. of Well Casing <br /> aetesticlPrivata {I Paclr 0 Traer Type eFCeeing: -- ,— Specifications <br /> I71 Public [_7171 Delta DWh of Grout Seal T <br /> I I kr' _ 4- Type of Grout <br /> Irrigation � rox. th " I 1 Eastern S*)ace`Seal Installed by } <br /> : _ <br /> Repair work.Dons Qr. "Type Pu H.P. _ <br /> Sealing <br /> _ ; <br /> Steel"We <br /> ..Doren <br /> Well Destruction ] WeG g Material (top 501) . <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WOAK.-- ALiAT"11 REPA144-ADDITI(N 1-I DE67AUCTION E.l" et#H pui�Ke sewer b <br /> avaflabfe v�thin }seta <br /> Installation:vW,wftr W., Ft Cart lercia# r Othet <br /> Number of Iiwrrg units•,. . Number"of 0a*ooms <br /> �r <br /> Character of a"to a depth of feet: Water table depth <br /> SEPTIC TANK_:. <br /> ('KG. TREATMENT PLT..❑ D <br /> nearest: Well Foundation Prop tty: <br /> LEACHING LINE ❑ N A Umlwh O,l Total ierva, <br /> FILTER BED ❑ D, gcrt; A"Rest: Wall foundation Aim <br /> SEEPAGE PITS 11 D+th _Size I�U111�r <br /> StthlPS L-1. D' Well foundation Property Line <br /> WSAL OONDS I] �. .. _. <br /> 1 hpnlby.cartify that,l:.htpne. :.... I ow the testi;VAftAW t t cpunty aadirrances, state laws,and <br /> rules and regulations of the San in Li adNolath lit.. 4 <br /> Home owner orru's ;"1 pCn parpntrp of +y4rk.119r,rIIIMGh this,pertnit is**W, I t not <br /> em Y anlr p m Much as to toecoroa .to►eonricmert's ►laws of ceiftrnia Contracl3otrs liking or sub-contracting signature <br /> certifies the folloJI:"1 Y.:_ t in the <br /> ..of:Bu4 uMQr1C-f .y .t rrrrltltl iatutjid,.lahail pertwrlseurbjectto tivtxluruan's co-perm- <br /> tion laws of California." <br /> The apfrl fore Oompbo.drowft MOD 1 <br /> X a <br /> Signed - Titi 1 Dm <br /> .f-3 3. <br /> _. e.,.- FOR�11��►119E'�Ilfftl�I LSE.Q11111G: yy:�� .•; <br /> Application Accaptati#tY. D '�V <br /> Pit or Grout Inspection"by Data. Fimala r Dan <br /> _ I <br /> 2&h� <br /> Additional Comments: <br /> ❑ Stk 4888781 ❑ Lodi 3110-3621 <br /> 1H 7104 C)Tscy <br /> Ax*mt- Raturrl a4.oapi",to: Env MUDIOW: Mr ;irviofaa=1-EKnelt n Ave., P.O. Box an,9*., CA SMI i <br /> FEE AeAOUW DUG <br /> INFO1TD t311SH RfCE1VED.BY GATE .PERMrr'NO. <br /> « tM 13-24IREV.1 8sl <br />