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APPLICATION FOR PERM" <br /> SAN JOAQUIN LOCAL HEALTH "rRICT <br /> 1601 E. HAZEL ON AVE., STOCKTON, CA �CT +Z g 687 <br /> Telephone (209)466.6781 H�L� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V1120MEiAt <br /> /SFVICES <br /> (Complete in Triplicate) EF��IT <br /> Application is harebY made to the San Joaquin Local Hcafth District for a permit to construct and/or inst38 the work harsh dax*tDed Thin appication <br /> made in compliance with:ion Joaquin County Ordinance No.649 for sewapai or No. <br /> 19U for wad/pump and the Rules end Regudehons of the Sar Josgt+in <br /> a t Local Heakft District. /CK0440 , / ���j/,/�/0i <br /> R� 'ICK <br /> / /-:t 74/ Wry__Md Loc Size <br /> �E. Job Address _ 2 � 4 � y 'dL— <br /> /�� 7 �1�1FeP.O Adm ger , ,Causes pl.11 r �' <br /> Owner c Nsme/Yok, <br /> Contractor's Name <br /> �Z > N)I� A PPZ- License No. �6 Ph'c M <br /> TYPE OF N/EU/PUMP: NEW WELL Fj WELL REPLACEMENT G DE3TkUCT10N U r tTE ', YY <br /> SYSTEM REPAIR C OTHER t? <br /> - PUMP INSTALLATION " + <br /> C DISTANCE TO NEAREST: SEPTIC TANK —SEWER LINES DISPOSAL FLD. PROPL <br /> . INE a <br /> FOUNDATION <br /> AGRICULTURE WELL OTHCR WELL PrTClStJMPS <br /> `�. <br /> 1 TYPE OF WELL PROBLEM AREA CONSTRUC ON SPECIFICATIONS <br /> INTENDED USE Dia_01 yy� <br /> D Industrial Ci Opetr Bottom 0 Mameca Da.of Wad Excavation <br /> T of Coaling.— <br /> $Pacifkatbns' , = K' <br /> ' c d Domestic/PtIVste v Gravel Pack C3 Tracy <br /> yreType of Grout ' <br /> ' rOther G Deka Depth of Grout Sas! —. <br /> Public, a. <br /> Irrigation. _ADPror.. <br /> Sr}aca S <br /> Dept, �Eastarr+ ' y� eel InstalledW , <br /> Repair Work Done L) Tyne of Pump H.P. State Work horx` *' <br /> z t <br /> Weil Destruction 0 Wetl Diameter Sealing Material itop 60 <br /> Depth_.—_ Filler Material(Below 60) <br /> TYPE OF SEPTIC WORK: NiIW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION LJ IN o septic system Wmkttsd i<PYbft� <br /> svakaDse wdM(n 200 teat.) t.:;• . <br /> Installation will serve: Residdtmc— Commercial-- Other <br /> r 4 <br /> Number of livirlg units:_._. Number of bedrooms Weer table ulaPth <br /> Character of soil to a depth of 3 fee:: — -- capacity ,Net.Corripsrtrt+ants' l <br /> SEPTIC TANK Tyler/Mtg — 4 Method of DNpoeat <br /> t PKG.TREATMENT PLL 13DaLrnce to tamest: Welt Foundstion Property Lis_. <br /> (� No.8 Length of I,nEs ._ Total krs$th/size -- — <br /> LEACHING LINE Line <br /> FILTER BED 0 Ulstr,nce to nearest: Wetl_ - Fovndatinn — property <br /> Number <br /> SEEPAGE P17S 0 <br /> !lepth Sire _ <br /> SUMPS t Distar-ce to nearest! Well Fcundatson Pr°DettY Line a s <br /> DISPOSAL PONDS ; ehMNYld►x>tnd• <br /> application and that the.vorlc will be done n accordance with Sen Joaquin county ordfrretvase <br /> I hereby certiry that I have prepared Ois �r <br /> #:.. <br /> rules and regulations of the San Joaq"in Luxal Health District.g t is lasuad'I"not, <br /> nt's signature certifies the fORCwm I cert fy that in the laws of encs of the work for which this peril <br /> Home rwrer or licensed ape or sub-oorrttaetirep tli4trturir <br /> emDlr,y any person in such manner as to become subject to workman's^oripensstion laws of CalAoenis'"Contractor's we t to tvorkmert B ; <br /> I certify that in the performance of the work for which this permit Is issued.I stw l ernPbY W { r <br /> canities the following: <br /> t�'.n taws of California." <br /> a. < <br /> r the applicant cer all uired insc <br /> . t c <br /> .Cmplete Jraw:ng <br /> ll for on rave. <br /> / lin Dote: <br /> signed <br /> s/ Title: <br /> FOR IAIENT USE ONLY <br /> Date��� T Ar <br /> Application Acceptsd by -looll <br /> Finan Inspection by ry —� Oste+1 <br /> Date ---- �i <br /> Pit or Grout InsJeo.ion by - - <br /> dltional Comments: -- <br /> 0 Stt .46667!31 0 Lodi 369-3621 <br /> Ad0 Manteca $23 7104 C1 TrsZY 935 <br /> /Sery <br /> gppl unt•Return 0copies to:Emironmental Health Perm tices 1601 E.Hszekon Ave P.O.Box 2 K>y,Stk., CA 95201 <br /> AMOUNT REMITTED Cs a RECEMO BY,- SATE NEHMTYNO." <br /> FEEEaMoIUNT:101VIE CA 3N <br /> INFO 24 I11:V.101911 - <br /> [h <br /> 14.26 - <br />