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<br /> SAN JOAQUIN LOCAL HEALTH LRICT
<br /> ! 1601 E. HAZE:TON AVE„ STOCKTON, CA r
<br /> x
<br /> Tell ona (209) 466.6781 '
<br /> PERMIT EXPIRES.1 YEAR FROM PATE: ISSUED
<br /> (Comptote in T;il)lir_atel
<br /> 5 " Applidarlon rs hereby made To the San Joaquin Local Health Dlsttir-t ler it permit to ennalruct and/or install the work hereln dasedbcd.TM%aapacaAnn Is ,
<br /> [; rturge in compliance with San Jnanuin Cnrrnry,Otdmince No.:d9 lot sewage or No. IB62 lot w Iljpurnp and the Rules and Regulations of the San Joaquin
<br /> Local Health Disuict.
<br /> Job Addnifi�_p„7..�n /1%1' s/1 KS - - City Lot Size PMI_ ..
<br /> Address _fATS--'- .Phone
<br /> jtrw' - -LicenseNo.
<br /> Phone.
<br /> Address ra er WELLREPLACEMENT _ UTON L-JTYPE DF WELL/PUMP,. NEW WELL 1.3
<br /> .` .
<br /> 777 -77 PUMP INSTALLATION 0 SYSTEM REPAIR 0 " OTHER 0
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<br /> DI574NCE TO NEAREST:-SEPTIC TANK. SEWER LINES _ ^_ DISPOSAL FLD. PROP. LINE {
<br /> FOUNDATION AGRICULTURE WELL __— OTHER WELLPtTSISUMPS
<br /> --�
<br /> rj iNTENOEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> } t � ❑lntlustrlal-: O Open Bottom ❑Maweca Dia.of Well Excavation Dla.of Well Casing
<br /> y L- 3`i I`)Domeitic/Private I7 Gravel Pack 0 Tracy Type of Casing Specifications- ('
<br /> i
<br /> �N :r qg
<br /> t�- n ti K tiff ,5i I Public , ' -M Other'! n Datta ..bepth of Gtplrt Seal Type of Grout.,.
<br /> i - �A' tp Fr .,�Ijrr hrrgaeion i r -�X j. Approx, ().6th t I Erstarn �' Surface S-1 Installed by
<br /> P.epeitWork Done L] .Type of Pump:- `-H P. - -" alae Work Oona_ , t
<br /> �g' tNe1L
<br /> ruction {] MenDian.ter Seafing Material hop 50'1 `
<br /> 'Filler Meteriai IBelow 501
<br /> O ,
<br /> i• r'> f t TY7 E OF SEPTI.WORK,i NEW IN''TALLATION 1 1 REPAIR I A DDITIONXDESTRUCTION1 I (No septic system parmdled d puW C savrar'es f t
<br /> available within 200 feet I
<br /> x'r ` A :• .y1� Irutallalbn wilt serve Rasldence I j Commerce[ _Other
<br /> Nvrnberof Itv1 units I Number of bedrooms
<br /> ;� ter ,r{ a �L edrY Character tet soq-ta a depth of 3!seri I+ra r 'Lnln Water able depth-
<br /> R111
<br /> epth
<br /> SEPTIC O Type/hRfg Capac t
<br /> r _ Y !No'ComperYmenta
<br />� F�y��' PKG TREItTMENT PLTt G1 � r{r v „ 4 �4 ,, Method of Disposal ` `�t'�` 1. �
<br /> f5 ':t ay �; •- r a } ✓ r °c 1' S.
<br /> G Dfslar a to heuen tWell' $d- Foundation Property Line_ _ +! !2 tifrc�ry x, : E
<br /> r. , -.s f•f fs-� Y��ti I �', n +iii ,1r.,�_..�i',iA.l?r' , - p
<br /> ! Y 1,4 LEACHING;LINE '"t r �I I'r Nod Length of tines
<br /> Total lengthlarrerf n�
<br /> y ziFItTERBEOA.� 4zyC5 Olsta<nce,iorwrest:' Well' Foundation Pr6tisnVlfns' ` °�S°rt ' t'rr ':
<br /> SEEPAGE PITS � - I l Depth:'-: She "Number`
<br /> rJ ec n SUMPS }�> i I�` Destence to neatest,:!.rWell Foundation Property Line y4 1 f
<br /> DISPOSAL PONDS' C]:;l
<br /> 7• ` '(-I hereby-pnrly that I haw pirpared this applicatbn'and thrt the work-wdt be done,n accordance with'San Joaquin county ordrnancea aceta lerrva and
<br /> ay ' rr�a+ulei-end taqulebrirof-thi;,5an Joaqulri LocaE:Health:`D3ttia
<br /> Hwns owta♦ryo►NcnWd ayuit's'sipnatun,ianif{ef_tfia,fa6owing i.cert(fy that,in she ponormanea ot.'the wixkNfor whkh'
<br /> this pxmit'k isstrod t
<br /> Ike ! -�mpbY'er�yp ori'in rltseh htannir as to brcorna;iubloci to.workman's'compenietion laws of Cekforriia:"Conlrador'■fitting-ci wttcenVeeling signaturo - •
<br /> o cadifrefi the folipwf 'f
<br /> - ^g y/I_eattity that In the performance of the work for which this_permit le fsiued I shell employ persons wbject to workman a companu w
<br /> }_ar' r r, N,,,,tliOn,InvY;ro}CrHroiitia r rssz i.wP„!y �',y�: 5ry,u -,zr, 5sa -ti'•.�
<br /> y�'t The,appfreant ri catl Tor`nil requ(red lnspecttons Cernoete drawing on ravetsa s do
<br /> "!tr i � P;"'^
<br /> Oats9
<br /> ^` } r w r dr FOR DEPARTMENT USE ONLY
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<br /> ' ,yt? �y - l' ''Apptieatlon.Aeeaptad by +` `• its.:
<br />� � } � .�' �-, r
<br /> rt Y 4 tk'� Fit or Grout msz lion by =�r Dati Fina!Inspection by
<br /> 1 o f �ist��ty�- `9 r{tF'�rr r� i :; i s-: s�,r•5. T r t
<br /> r�`Additional Commenp y. )
<br /> l 1 f O Stl( A88 6781 $ D Lodi ,W.3UI 7 j .0 Manteca r 823 7t04 } f 0 TrscY 835 8385
<br /> AppZ-61M Rrturn'ig eopirs,to Environmental Health Permit/SarvkH-1ti0t E Haxel[on Avi P O Bdx 2lb9-Stk CA rj5201 '
<br /> �` Ikltk ?INFO_ ,'."�AMOLINT OIfE� ,j A�10UNT REMIT O ri 'RECEIVE()eY :,+ .'OATEI PEHMn"NO r✓ iN r
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