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11 <br /> ' APPLICATION FOR PERMIT a <br /> s' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephcn)e (209) 466.6781 <br /> PERMIT EXPIRES I YEAR FROM DINE ISSUED <br /> (f„ornplete in Triplicate) <br /> to licatinn is <br /> L <br /> APPt;catkll Is hence with Sano the JOSqu nnC ou ty ULU nalncle Nto,549 for sewa4Re or No. 1862 tor 4we l/Dunn)at and!or tnd the Atalt the oes rk and IRegulalions of the San Joaquin <br /> rnada in car}1p iF <br /> Local Health District -03 _r StA) J-O*Y✓YV <br /> Lot SiZO �-- PM <br /> Job AddreCity ss - <br /> A- -V/ttl IfvBG /� F <br /> � -Zz9l Gy-y1/���ZGr F�rRG SYS lva,J3 Phon�'e'_"��2U'9_ <br /> Owner's N01118 <br /> Grv�u_ l. n � - Address Sc,� •✓ C� y/5 <br /> AVr r� Phone <br /> C:vr6ir� /.ylple�y/Cr�e c_ AOdfesst�lOo�JuE(lSt !� ✓�. License No.�v�r.—�— <br /> 'r .. — DESTRUCTION NSI up0,4-&14 43 <br /> TYPE OFIWELLlPUMP: NEW WELL J WELL REPLACEMENT C'. 5o/t_ e3v+GinGs rb <br /> "•'- � '� —___.. PUMP INSTALLATION C] <br /> SYSTEM REPAIR C-1 OTHER ( z r $tx,nw GtXOr <br /> S_WER LINES _ DISPOSAL FLD-_ PROP. LINE _..-- <br /> DISTANCE TO NEAREST; SEPTIC TANK — — — PiTS/SUMPS _— <br /> — —ib— _FOUNDATION ,- AGRICULTURE WELL OTHER WELL -- -- — —. <br /> WTENpE6 USFTYPE OF WELL PROBLEM AREA CON ST.RUCTION SPECIFICATIONS pia. at Well Casing <br /> I_' fl...en Bottom i"1 Manteca pia. of Well Excavation...__ — <br /> 111ndusirial — p _ Specifications <br /> I -i Gravel Pack L7 Tracy Type of Casing. . <br /> I 1 Darne�stic/Private Type of Grout <br /> i 1 Other �l Delta Depth of Grodt Seal I <br /> ('1 Puhli 1 <br /> Apprnu. Depth t ) Eastern Swfaca Gaut ins[alled by � L� <br /> I ! Irntlaticf, -- _— Statfr Work Done - — -- — <br /> Repair Work Gane t.'. Type of Pump _ <br /> Well Destruction L! Well Diameter -=r- Sealing Material (top <br /> pepfi Filler Material (1364-v50') <br /> TYPE OF SEPTIC WORK NEVI! INSTALLATION ( I REPAIR/ADDITION t 1 L)ES'TtILIC:TION I ! INo septic sv5tefn permitled ii puhlir, siswer is <br /> available within 200 feet.) C ; <br /> Installation will sen•e: Residence — Commercial �.r Other---- --• r <br /> Number of bedrooms— - <br /> Nurt[ber of living un(ts- - Water table depth ----_ <br /> Chara ter of Soil to a depth of 3 feet: .. -- �- No. Compartments � <br /> Capacitya <br /> i 1 TypelMfg _ <br /> SFPTtC TANK Method of Disposal <br /> PICC; TREATMENT PGT. €_I _ Property Line Distance to nearest: Well — Foundation — -! <br /> -- l length Site -- r <br /> ---, Tota - <br /> LEACHING LINE t I No. & Length of lines --- Property Line <br /> FILTER fjEp Ff Distance to nearest: Well Foundation —_. - p y <br /> fhtmber <br /> SEEPAGE PITS Y 9 Dept .— --- --- _ — <br /> SUMPS ti I Distance to nearest: Foundation_ <br /> Properly Lind <br /> k <br /> OJSPO.'SAL PONDS "-I <br /> t hereriy certify that i have pragared this application and that the work will be dune in accordance with San Joaquin county art4inarces, stats taws, arlri� <br /> rules and regulations of the San Joaquin Local Health Di$trict, <br /> Homeowner or licensed agent's gignettue pensation taws of California." Contractor's hiring ar su <br /> certifies the}oll4wing: ") certify that in the performance of the work far which this permit ig issued, I shalt not <br /> employ any person in such manner as to became subject to workman's com �contractrng s'9nature <br /> "I certify that in the performance of the work for which this permit is issued,I shall employ persona subiect[o WorkAlOn's COmpenSa- <br /> certilias the fallowing; <br /> tion laws of California." sCC-- /�l`777 GH�� <br /> The applicant must call for all required inspections, Complete drawing on reverse side. <br /> Titlo: �0�--�'SC�PL - Pate: 14" as` <br /> Signed ' <br /> Ff� AR USE ONLY � --7 -- <br /> Date_ Feb �G <br /> Appli i ation Accepted by <br /> par <br /> Pit a.r Grout Inspect'on by _ Date w_'—"—" Final tnspecuo <br /> AddIl a ional Comments: ,___� <br /> (. Stk 466 678f Ll Lodi 369-3621 6 <br /> © Manteca 823-7104 0 Tracy 635.638 <br /> permitlSarvices 1801 E. Hazettgn Ave., a.0. 90K 2009, Stk., CA g524i <br /> Appllcant • Return all copies to: Environmental Health <br /> CKRECHVEA 9Y GATE PERy117 NO- <br /> FFE AMOUNT OUE AMOUNT REMITTED GASH <br /> 3� too }�� r � Zr�9 � i 431I <br /> f"11.14 I#EV 1,nni <br />