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<br /> APPLICATION FOR PERMIT
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> 13M E,, HAZEL ON AVE., STOCKTON, CA +.
<br /> Teiehitara (20914606-6781
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED }
<br /> r
<br /> (Cornpiete in Triplicate} e.
<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct endlor install the.work herein described TMS applkation b� i h
<br /> made a on is a hereby
<br /> with San Joaquin County Ordinance No:544 too sewage or No.1862 for wellpump and the Rubs and Raguiations Of tlfa San -
<br /> if'ra' ?Er' rte r
<br /> :I oalth District.H
<br /> City
<br /> d 620_P 'S Lot Sita [
<br /> ' Joh Address -�-�---�3 w
<br /> Address ADO
<br /> Owner a Name
<br /> License NO. �L�K
<br /> Conlrat lo7-- d 'G�t/` �---Address _ ,
<br /> 1 NEW WELL ❑ WELL REPLACEMENT C] DESTRUGTfOk ❑. w " i
<br /> TYPE OF WELLlPUMP ;..,- SYSTEM REPAIR 13 " OTHER Q
<br /> .r PUMP INSTALLATION.❑ _ DISPOSAL FLD. ._PROP LINE-
<br /> DISTANCE`TO NEARE SEPTIC TANK�. SE�NER'LINES -
<br /> 77-7-777 FOUNDATION
<br /> 4GRiGUt'TURE,WELL OTHER WELL PiTSISUMPS
<br /> INTENDED USE TYPE OF.W�LL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS
<br /> - Dia.of Wsl Casing ,
<br /> Cl Industrial
<br /> open sattort+ , 0 Manteca Dh:of Wel Eauvation:�--�.,�-- 51 t t _ 11
<br /> Gl DornesdclPrlvate ❑Gravel Pack Q Tracy
<br /> Type of Casing a
<br /> ". .. t f1 Other fl Delia L �. Depth of Grout'S"I ' Typo of Grout
<br /> t 1 PublrC Y
<br /> I l Irrigalwn Y x Approx.Depth -I.I Eastom 5urfaco-Serlrlrntallt♦try f .
<br /> of Pump' '1 C P State Wbik Dom �» ti`r �, '8
<br /> Repsu Work Dona> [] Type 3 ►
<br /> 4iy We!Wtsfiuclion C7 " We!Diameter. Sealing Matarhl Itapr60l r t; ��� .ti• e
<br /> Depth__ — - ' :filler Material(6ekrvr 50
<br /> _ Wftwww *..�
<br /> NO
<br /> TYPE OrFy.SEPTIC WDRK NEW INSTALLATIO REPAIRIADDITION DESTRUCT apN I I Ia faeEllK'�
<br /> ����
<br /> Commercial .L Other -- ' ,
<br /> k` s Irtalalatbn win artvfr Raaklenca # } AN "
<br /> *: INing.unilt ?3`" Number 0!bedrooms- 3 i Water Sabi!dlipth ' Sash r
<br /> s Number.of
<br /> �T,+r' °Character of so N to a depEh of 4 feel. j g �; Cwvlwfn
<br /> �
<br /> V� SfPTIC•TANKrr ? C3 r`TypeMfp Capacity! Method of DiEpoata
<br /> fi PkJ TRFJITMENT PLT CI ' FamtlaU in P►opeKY Lim
<br /> >t 4i a�tr-r': h a. •,.x la �Jt Distance 10 nearest: Wel- I'
<br /> i
<br /> f s
<br /> r hotel I
<br /> sit
<br /> i� LEACHING LINE }No E Length of fines ��
<br /> �j,yy,� •f'roDsnY Ling
<br /> Flt 9EO" t'x 7x .£_Dktanca to nearest: FOCirldatlOn
<br /> • , FIL 1 Rr
<br /> ' % rESEEPAGE PITS °tai ` tl ':Depth.----��5`» Numbery�
<br /> } r Wel Four.detwn i>Pe
<br /> any `.�SUMPSrt .1 i k L] Distance to nearest: , , � yr r ,,? ;-- x..
<br /> s * 'DISP05AL'PONDS'r ., C] fn polrrrw�arafats fawn:"ands
<br /> ` F rad thh-apptieation and that the wo+k wal b.done in accordance with San Josau ' .�
<br /> Y, , meg'1 herby cwIty'Ihat l how preps!
<br /> ,tk r,,uhd and tr:"t{ons of the Sen,loayuMt Local Fbaith Dritrkt h that in the Wit" W011 of the work f«whicf+chis psrtNs ► .
<br /> t s►6h
<br /> x�y s Homs orrrra'or...lkwood apsnt's signator Oertifies the ft to workman s cumpertsation Iowa of Cafrfornis."Conhactors hiring a
<br /> "joy any p_m in such manner as to become wbOcl ttta work for which this Permit h iseue� r< employ perms K60Iet to wOrkmada
<br /> the followNyg T cermy that in the P o
<br /> %tion Uwe of Calfomla 1^ +�, e
<br /> 1 a t�rNiras t-tel}« raquind inspacttone Comom o drew"on rawirrreq�,a,�,��'a s•. �'T,4".: � •`..Aye.
<br /> ' ?I {Ts»�r.! J��mua a # 1 F Onto:
<br /> �Ja 5 k r✓ a rF •, r z S 'rs ,,� s y '�,� .a jeL� 3
<br /> Y ti � ' x FOIi PAR7f1AENT USE ONLY
<br /> � raF+° Ytr r j✓ /lf
<br /> tlen Accepted by rV
<br /> APa �j �,��,xx
<br /> r r„t '.
<br /> Pit«Gr0u1 lnspsction 1ry-�
<br /> Additianwl COrttntanlw 1�! ,- k#lt , `' 'i' ti'yrt
<br /> k`. .l�Stk`r AR8 6781 O Lodi 3fi9 3fS21 C}Mont**-, 71f11 1 d Tracy 1> d�6 '" 't`A r�aF A
<br /> ta1_Hnith PsrntitlSarvkes tf7p1 E Ha:Nton Aw' O.ku 2009.Stk;G 9fi?01i
<br /> "4 Applicant Aaritm al capia'to Emr!^onman « r
<br /> k`. '� •y 1 _.�#� ':s,r w" c�S{'"' air+ �w N�'9 68" $� -.
<br /> �`4 i y, 3acia7Yy�fA. 'Y,Nwo - h r,•, C
<br /> FEE
<br /> AMOUNT item
<br /> TTEC-a:: CASH
<br /> .r°—•,+...--• N •'"£-•—•--.•.w-�'^" M.r� -�y�i.'^'ay< -:�',��at ��r �'�i
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