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APPLICATION FOR PERMIT AlYoe
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA
<br /> Telephone 12091 466.6781
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> -T IComplele in Triplicate) —�
<br /> Application.s hercby made to the`,w .t. ::•+I oral Hnalth D'stncl lot a permit to construct ar.d/or etstall Ilia wwk herein described This Isgocehesn s
<br /> made in complianco with San Jodqu-t oi&,,.mcu No 549 tot sowat"or No. loQ fogy welllpurnp and the Rwes and Repulattons of the San J0 11eln
<br /> Local Health District.
<br /> Job Address city Lot San PM
<br /> Owners Name 11 IC+t�r.d�.J ---- Address _�., 1Lu Qct - " pt..
<br /> Contractor y :.n,4rrss ,!_��` _yam^ License Nt�- 1�7 _ ~
<br /> TYPE OF WE_LLIPUMP: '.f:: VFI t " I WELL REPLACEMENT 1 1 DESTRUCTION I I
<br /> PU AP IN! FA I AT ION '" SYSTEM REPAIR 11 OTHER 11
<br /> DISTANCE TO NEAREST: SCI 'IC ANN _. SEWER LINES DISPOSAL FLD. PROP. LINE
<br /> FOUNoA[if •i AGRICULTURE WILL _. __. OTHER WELL_ PITS/SUMPS
<br /> INTENDED USE TYPE or %Yt I I PROBI EM All[A CONSTRUCTION SPECIFICATIONS
<br /> ( 1 Industrial 1 I Open Rott.•••• I ; Manteca Da.of Well FacaWtion+� Mr _. Dta. of Wen Casing
<br /> I I Domeshc/Private 1 1 Gravel P...i 1 ' Tracy Type of Cavntl- ____ Specifications
<br /> i'I Public I orhur I Delta Depth of Ghxrl Seal Type of Grout
<br /> I . Irrtgat.on Appm% th•olh Esstetn SutIALs Saul htstolled tryRepairWorkWork Done d Type of F'w :• ��s� ._ HP _ _ __._.-.._�. State Walk Dom
<br /> Well Destruction Well
<br /> Depth FdMr rlalenol(Bebe 50'1 _ - --
<br /> TYPE OF SEPTIC WORK NF W 1N'0 AI t A 11ON , I III I'AM ADDIIION 1 1 DESTRUCTION f 1 INu aeptrc system permitted if pubic sewer rs
<br /> available within 200 feet►
<br /> Installation will serve Hestdeme l ommern;al , Other
<br /> Number of living units. _ Nu..,1••• -4 F,edrooms _.. _.
<br /> Character of sod to a depth of 3 b•,•t __.__.— __w Water table dFrpth
<br /> .,N' SEPTIC TANK I I Type'Atf, _ _. Capacity _ No. Compartments
<br /> 1 PKG. TREATMENT PL T Method of Orsposal
<br /> Dista,+ n.•.uesl: Well.._..�_ foundation Property Line
<br /> LEACHING LINE 1 ' No K I.•.,n'•,..f Imes _. ..____._. _ _. . _ Total k►ngth7slre _
<br /> FILTER RED I D•Nla- + • .r..•at Wall Foundet.nn .__ Properly
<br /> SEEPAGE PITS _ Daprh Sue -_ _Number
<br /> .y SUMPS t Dva-im.• I .........st Well Fo.ndat•on _ .. Property LrHcALTH
<br /> DISPOSAL PONDS PFi2MIT I,FNViCFS
<br /> 1 hereby certify that I haw-prrpam,l It .;!..,'.nn and to•t nw %nii, %41 1..•dune in a,.r nrdancn with San loaqu,n county ordinances, state taws, arwt
<br /> rules and regulations of the San J-,r Health D.:.1t-,
<br /> Home owner ur licensed agent s aye ++ the fatluw:nu '1 certify that w the performance of the work for which this pMmt K issued, 1 sties not
<br /> employ any person in such nutnro.. . ,• ,.,subp.rI to wurkman's rompensarron taws of California•'Cnnuacrocs hiring or sub contracting sgnature
<br /> certifies the foltow.nit 'I rani. 11•. +• ;•�'•„martin n/the cork tot which this permit-s issued,1 shalt employ persons subreci to workman's Cornpensa
<br /> tion laws o1 California ”
<br /> The applicant ma II n, .111 .•(� , !� •r•♦ Cr, 1-Into:h�.%I,,I g on reverse s,Ae
<br /> %' nailX `llC/i/�rC•--=� / r -''� �^/eOZ/= --- - Dale:
<br /> FOR DEPA7TMENT USE ONLY
<br /> Application Accepted by )'O�• (I U f-_k}J__. _ Date,1 L_✓�-- Area -- --P.I
<br /> Pit or Grout Inspection by U. _._- Final Inspecuon by J� Dote3
<br /> Additional -
<br /> i ' Stk 4%6781 Lod, vrt +'. ' Maniacs 824 7104 f.1 Tracy WS 6385
<br /> Applicant Return all rowo%to F•. •+• m, Pr.r.rnV Services Ib01 E. Harelton Ave, P O. Box 20(19, Stk., CA 95MI
<br /> INFO T -AMOr N, I nvr)!_,IT 1.1MtTTED- CASH - TRECOVED BY -D1ATE PERMIT NO
<br /> Oq
<br /> 1"13 24 411tv
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