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APPLICATION FOR :'EHMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZYLTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> j <br /> Apprlt~is hereby Meda to the San Joaquin Local Health District fC•a pnnnit to construct eM/ar transit the work herein d"~.Thr aPpaceibn+ i <br /> made in Compianee with San Joaquin County Ordinance No.See for sewagro or No.1862 for well/pump and the Rules and Regubtions of the San Joequln <br /> i Local Health District. i <br /> /037 fanee !10 _ Cif O Lot S <br /> ry Size I'M <br /> Job Address ,Q�G/ s <br /> pwyer's Name C&OFIXV,J I�(fC'�'� Address �"z ` Panne <br /> A �n�L- '7"Z L� Zo16ee0/ PhoneAr6r76/Y� <br /> Contractor <br /> /`�� RCerr qAddress 3'�� w" License No. i <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION L1 r <br /> SYSTEM REPAIR ❑ OTHER ll ' <br /> PUMP INSTALLATION O PROP.LINE <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.__ <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> G Open Bottom G Manteca Die.of Well Escavaten Db.of Wait Casing I <br /> u Ireustrial specifications <br /> 0 Dpmestic/Pdyete ❑Grevsl Pack 0 Tracy Type of Casing_ <br /> G Public <br /> C Other ❑ Dale Depth of Grout Seal Type of Grolit <br /> I E)irrigation _Appros. Depth G Eastern Surface Seal Installed by -- Q - <br /> Type of Pump H.P. State Work Done .•, <br /> Retrial,Work Done [I - lY <br /> Well Dest,actipn ❑ Well Diameter Sealing Material(top 50.1 <br /> Depth Filler Material(Below 509 _ J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C REPAIR/ADDITIONr/pESTRUCTIONa INo asptic aynem permdtad d Woes:sewef s . <br /> ` evaileble within 200/eet.l <br /> Installation,war serve: Residence— Commercial— Other <br /> Number of Ih mg units:— Number of bedrooms <br /> Want table depth d <br /> Chander of sea to a depth of 3 fast: <br /> G Type/Mfg Capacity— No.Comparthems <br /> SEPTIC TANK Method of Disposal <br /> PKG.TREATMENT PLT.C Property Llre <br /> Distance to neaten: Well Foundation_ pe � <br /> —� �0 Total length/size_ <br /> LEACHMG LINE Q°�NO. 6 Length of renes <br /> //���// 1�_ Property Line <br /> FILTER BED C, Distance to retreat: Weil�p�_ Fountlation <br /> Size Number <br /> SEEPAGE PITS C Depth <br /> SUMPS Distance to nearest property Line <br /> well Foundation_ <br /> DISPOSAL PONDS L <br /> I hereby Candy that I;leve prepared this application and that this work writ W d cod Ih SanJosq n coca ry ordinances <br /> nate laws. <br /> end <br /> rubs and mgubti"of the San Joaquin Local Health District. <br /> Hprnc owner a licensed egem's signature cartdbs the following: "I certify that in[he performance of the work for which this permit s issued,I atoll nos <br /> emplpy any person in such mender as In become Wbre to workman a compensation laws al Ceffornia."Cantn<tols hiring or suRcontrectirtq <br /> nature <br /> Certifies the foWwir[g:"I certify that in the performs"A of the work for which this perm;[is sauod,1 shall employ persons subject to workman's tomµse- <br /> Bon Laws of Calilomie: <br /> The applicant mun tall requir in Complete drawing On averse side, <br /> �G1?rrl%l Date: <br /> Title: <br /> FOR DEPARTMENT USE ONLY <br /> � _. Date �_ II.7 Are. <br /> Appli,,tlon Accepted by +-a—'�T�'•�' --_ --_ �// I , Dne J <br /> �f F,na, 'nspxl'an Or f j--f{--F�-f�� <br /> an by r"--r—'__ Date __ <br /> Ph oc Grout Inspect <br /> Addnional Comments: Tracy 83rsE+85 <br /> G Stk 67a1 Lodi __ ti11 anteca 823-7104 <br /> Applicant. Return all copies to: Erwironrrentzl ea 'h P8, Services tB01 E. Haiziton Ava.. P.O. Be.2009. SI4.. CA 95101 <br /> iERECErvFD BY E AMOUNT DUE AMOUNT REMIT-TED C`(� DATE PERMIT NO. <br /> ED CASH _ <br /> INEO <br /> ' 'W <br /> O` � <br /> .[,r 13 N IP[V ' <br /> oaf ` (vp =15-15 JJJ <br /> Fn LLA <br /> V� <br />