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F <br /> 3 <br /> rq APPLICATION FOR PERMIT 4 <br /> rs SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E -HAZFLTON AVE., STOCKTON, CA <br /> Telephone (209) 466-Ml <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Cornplete to Tnpficate) <br /> App cation is haatrf rude to the San Joequrn Lou!Heahh District for a pe~to coratruct and/or kWO dw work 1wein described.Thisappor 'M is <br /> made M compiarws with San Joaquin County onsnartca No fa19 for sewage or No 19W for wwe#lpump and the Rules and Regulations of Ow Son Jawri rt ,1 <br /> Local Health D.stnct r � '`sw'_ ���`��A�, <br /> .lob Address -Z- ..S • ![T`71Y CayC CaE>IIt�R5ie� -PM !�` i s' <br /> f Add _,a_ V 3 s Ae <br /> T� <br /> t]wrwara Name �. --- +fir 1 <br /> Contractor (Address /d Z License Nol.423 3 Phata �f< <br /> d6 7� <br /> TYPE OF WELL/PUMP NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION FJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR !� OTHER ❑ <br /> DISTANCE TO NEAREST SEPTIC TANK I �_ SEWER tiNES DISPOSAL FLD PROP.LINE s, <br /> FOUNDATit'Y AGRICULTURE WELL OTHER WELL PITS/SUMPS �^ ��}� <br /> INTENDED USE T"C OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F <br /> ❑Induttlef ❑Opra+cotton - ❑ Manteca (No of Well Excavation - Dio of We@ Ceslrtp <br /> 9wN96espc/Pnvat6 ❑Gravel Pack ❑Tracy Type of CmkKl Specifications <br /> p Public ❑Other ❑ Datta Depth of Grout Seal Type of Grout <br /> + ❑Imgatron /— ApPrc Seal installed by 0a <br /> �/ H P State Work Date y{ 7 <br /> Repan Work Dane Type of Pump <br /> WOW Destruction ❑ Wert Demeter _ t sea"Material(top 50') <br /> Depth I Eller Material 18elow 50'1 <br /> r TYPE OF SEPTIC WORK NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION❑ (No septic syswn perm0tted d public sewer is +_ :J,'r, <br /> available within 200 feet I r t <br /> 1 Ur',SS.0 <br /> R Insbs!letion wdl serve Residence.,_ Other <br /> Pc Numtw of WvV urn Number of 1 <br /> Water tabic depth <br /> Clharacter of sad to a depth of 3 feet <br /> ICapaaty NO Compartrnents <br /> SEPTIC TANK Q Type/Mfg <br /> Method of Dnposd <br /> PKG TREATMENT PLT ❑ ! <br /> Deinnce4' to r-@~at Wert Forudatkm erty PropLite <br /> r 'a <br /> I LEACHING!_INE 0 No ti Length of fines — Total kengthlssz� <br /> :f FILTER BED ❑ Datance to nearest well Foundation Property Line <br /> - C' <br /> r , 7. <br /> SEEPAGE PITS ❑ Depth - I�Sens Number ,"F <br /> SUMPS ❑ Dutanos to nee" Wed Foundeboo Prop"Lkw <br /> DISPOSAL PONDS ❑ <br /> 1 hehaby eertr(y <br /> prepared this�erd that the work tMlt be done k s000rdanoe with San Joagtrrrh oo mty orrrahencea,state lewra.end r <br /> ! _ rhea and n na of Joaquin Local Datrtct s <br /> " Homa ar Goanaed a dpnatzue oartis the following M certify that in the pwfonramx*cf the work for wftkh this panni[k kuned.I*W not <br /> army I—in such as to suboct s omyo nsabon laws of Csiforria.-Contractor.hkitg or subtnntraedrtp slw-VA e <br /> o' slwR tQ rworkrttan's oorrhperwF,,� <br /> fobohvkg "I in n work for wwtnkh this parmi[fa katsed 1 erthploy pereorhs subject <br /> tion of CaMortra <br /> The on <br /> •, r r <br /> S, is r M14 i <br /> DEPARTMEW USE OKLY <br /> i Appfictqn Accepted Off, Area <br /> ; S Pit a Grout Dam _ YFkrf hnpection by <br /> ' . <br /> Additional Cannrrtenu. �-�-�- <br /> ❑Stk ,OB 6781 f][mf 391 r ❑Marttars t�3 ala' L]Trrgr 83Sb3i T <br /> c , <br /> s ' AppacsM.lteprm ss copies to Errvhoratwsrttal Health Perndt/Sarvioes 1601 E.Ha3yhun Ave_,P O Bou 21 1 Stk..CA 95M i w YY�;E_ a <br /> �.ri sgRATED RECEIVED By OATS <br /> AMOUNT OOE r C�lSfi <br /> = .tier to x raev h.•*ice. o o I �3GF7gT�i$ f i r y <br /> of tt7e_s . -.`.� W ,.�.F+[ r� .`` ''iLc»- ,. �..-... .., �.-. � .. .-• ..>-.-+2... o'��,r ,A' S t �,�r <br />