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I S
<br /> APPLICATION.FOR,PERMIIr"`
<br /> r SAN JOAQUIN':LOCAL HEALTH 01STRfCT
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<br /> a,9 1601 E. HAZE'TON AVE STOCKTON, CA �
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<br /> Telephone 12491 4656781 f i .,y. ^ ?sj1J� r' '
<br /> s 'sa ,u� .. ..,
<br /> ilir`r 4 PER EXPIRES 1-YEAR.FROM BATE ISSUED4rrti
<br /> {COmplete ill:IripliC8t9}
<br /> `'+a+'R�♦ C.'. l 'r t, ',�i _ , '. � r~
<br /> r .,itT t s{r� zapLocal
<br /> Applleetlon?�borsht made to the San Joaquin Orc'ranee No.D for for
<br /> or iNa.1882 for welll rump and the Rules anted Reyuiatkxn rrf t!►e 5an Mt Y
<br /> made In'C�frtpliance with San Joaquin County p 1 ,a 't'!y5 r 3 wrn r is ;.�,.�s
<br /> _ - 7 j� ak k°7tsF
<br /> 1 �rG��e,tLoeal Health`Dlatrlct � � � , °ms's ' ?�� r tr 3:{ .1.� „r?-r���o "+y,�rt uti '�eLt�F� ✓>r�5 ! ;
<br /> s.. Nr
<br /> Clty C 0 Lot Size o ( wde
<br /> a� ryUJoh Address¢ „J {s ! {rn ki is
<br /> Phone
<br /> Address !
<br /> AL�
<br /> �ttt v ' PhoneF -^
<br /> o„Cont'rec'ior s`Neme �� Licanse No
<br /> DESTRUCTION ❑s `,
<br /> �n1TYP60FLVELLIpUMP a r,, r ;NEW WELL.❑ WELL REPLACEMENT,❑ ,. t
<br /> r r ,`SYSTEMREPAIR'❑ 95 ti._OTHERi ,:ou`w.1rM�af �r� „�irr4j.,�g.
<br /> y PUMP IVSTALLAT ON`❑ pROP LINE s � al9 '
<br /> lg"'l � _ SEWER LINES p1SPOSAL FLp a OISTANCF;TO NEAREST Sun ,TANK c PITS
<br /> --FOUNDATION
<br /> AGRICULTURE-WELL' OTHER WELL
<br /> y. [
<br /> ;wtim INTENDED USE T'(PE LL PROBL�EM AREA ”'CONSTRUCTION SPECIFICATIONS
<br /> pia of Wali CeeingrR
<br /> Bottom ❑ Manteca Dla of Well Excavation -- a1 a r
<br /> svrx*FtJF��❑kndustrial ���. _ -Q Ops
<br /> �rC s Gravel Pack ❑Tracy ° c Typo of CaelnA y
<br /> ,�jt ;C3 DorrSestlL/Prlveter ❑ ❑ Delta Depth of Grout Seal Y Type of Grout''
<br /> ,M"s �, y❑ PUbIIG'4r� �� r ❑ether - r ' t lE } - R}y 'i+
<br /> ?ti �}t v;' t -Approxi Depth ❑ Eastern Surface Seal installed
<br /> ❑Irrlpatb ! $tate Work Done C � .
<br /> �7 •fir, t o-. -1H.P. _ ..t ..+-.,c,.� n',�--•'p- .t~�.
<br /> r 'RepaitsWork Done ❑q?Yp4 otJPu P
<br /> s` >Vall DestnictJrin ❑ We11 biameter' Seating Material atop 501y. re�g „-
<br /> L y a t
<br /> Depth Fllloi,Material(99{0 1 •n
<br /> Dep Itted it-publk newer Ie` y a�;
<br /> "r 3�sus TYPE OfrSEP71C'WDRK NEW INSTALLATION❑ REP, 0£STRUCTION❑.ef vellableiwith n�Ir feet lAY r tt yu Yet �1Ye
<br /> +Syrza'�Inetalletlon well serve ,FResldence Commercial Other 45 l { z </ �2
<br /> "NumbeKOf�IN ng units ' Number of.bedrooms Water tette depth ,
<br /> yy�i{'h�,(SN��'r v f•t o-. .!1 \ J A ''.
<br /> �$`;"�� Ctiaacter 040111'o a depth of 3 feet x _;,.
<br /> Capacity Na Compartments { N 'aJ x, S
<br /> 5s}a1SEPTIC TANKrn` !rte r ICJ, TypelMtg -�^�� �J
<br /> z r Method of Dfepoasi r
<br /> - - '6.1""., f �,.s J xfr•r� a�4y�i,� ��.g
<br /> PKG TREATMENT PLT ❑ t tx r" Property Line=
<br /> _Distance to nearest Wel{= Foundation
<br /> Total len thlsixe
<br /> !. --� NO-&Length of Imes / g n r+, "t-ik•-st r ,rw: t,,,a.
<br /> y #9LEACHING Ltl (/, t_ine
<br /> rS FILTER$ED>"' 1 v❑ -Distance So n9arest
<br /> Well'.yLi� Foundstlon "�-� Proportl
<br /> +,4sx' r, J,yS{:
<br /> 4 s y /-.;, Number he ifr t t a
<br /> s ter; y Depth Size I a >,
<br /> e�fort �-_:PropertYtln9rs�cs` ,4 y
<br /> ? SEEPACaE PITS M � ,
<br /> nearest:"" Well" � Found
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<br /> "DISPOSAL PONDSE 4, ❑ -�-
<br /> red this;appticatton'snd that the work will be done In accordance wit;,San Joaquin county ordinances erste fawn' r
<br /> hereby:ceitHl:thet'I have'prepe
<br /> ruler+and,;►egutetiona of"tfie San,Joequln Local Health Distrlct� "
<br /> ri r g, that in the peAormance b!tfie rk'for whlcl [tris pemdt Is issued 1►1teI1 not�ir'+�
<br /> f�T � 3 home owner or,Ilcer,sed e9snt s"signaturo certifies thtt follewm E tertdy nsetion laws of Caiiforrla Contrectofs hiring or sub^onlractEa9 aiQtfaturet '
<br /> ys 4 amplay arty person In_aua h'menner as to'Ueeome subJt ct to workman s comps ! rsons sub $tworkmen ti comt•ense r`
<br /> "kiy F f certHies tfse following I Certify that In the performance of the work for which this permit Is Issued'1 shall employ pe r J
<br /> r ,tion lewe'o'CdlHtimlB '.i.f 1^k't -... :..-r :.I d x
<br /> AW. The applloant ca11 for all d'"'nepeitions Gompleta drewing an reverse rs Dam
<br /> Title' x w * k f ritF �h'S"rl
<br /> xyv r J Signori
<br /> i i§,i s5 i 1 is foR DEPAfRTMETfT USE DNLY f fip i t s r} U tS�
<br /> Sy z " Appilceucn Accepted by Clete ';
<br /> mTt'�Y 7 �r aFinal Inspection by
<br /> Pit or,Grout Inspection
<br /> b"'y
<br /> �Mrr .517.', rc..,
<br /> + �Y t ddlttonel Comments 1
<br /> �r°❑Stk gaff 8781; f 0 Lodi '3� 1 ❑Manteca B?3710d ❑Tract/ :4 a sir _ R
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<br /> '°9 Applicant Retum c1l aop{es ta'Environmenrsl Health parm1t/5ervit�s 1601,E'Hazekon Ave P D`Bax 2009 Stk CA 96201 r t a Y
<br /> t ;PEAmrr NO
<br /> i,FEEo s t RECEIVED By i DATE
<br /> INFO 'AMOUNT DUE. AMOUNT REMITSE() CASH s
<br /> f ;�cf� H 147e EM I�V(REV.OlffiY i--.r 'i�,- +-_, �� ��'-i?, L Ar t`��'�i��,��✓
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