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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 468.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ <br /> (Complete in Triplicate) <br /> ADOilicMbn in haaeby made to the San Joaquin Local Health Dirnm tc•a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.648 tris sewage or No. 1862 for well/pump and the Rules and Requistions of the San Joaquin <br /> Local Health District. <br /> Joe Address `3d City of sire PM <br /> Owners N.- -k - La Addreaa —PAix 6- S` /1 M C <br /> 06.4 Phone <br /> ~ <br /> Contractor, hll dress d License No. 1--74?"1 Phone <br /> PE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION 40— <br /> PUMP INSTALLATIO SYSTEM REPAIR O OTHER O a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES —4-21Q 't DISPOSAL FLO. /90'f' PROP. LINE me d" <br /> FOUNDATION AGRICULTURE WELL 1-&&&THER WELLY- PITS/ScJMFy_ <br /> oauoED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r V, <br /> U IirtdlrelrW C'Open Bottom O Manteca Dia. of Weal Excavation <br /> f Dia. of V. =asktg W <br /> ?CDartsatic/Private C7 Oratral Pads C3 Tracy Type of COsinq_,.'��3y SpacifKitkvn 0 <br /> I I Prublic n Dalts Depth of Grout Seal Type l6 it ni <br /> 1 bargalaon _Approx. Depth I I Eastern Surface Ssaal Installed by �' <br /> Repair Work Dore U Type of P � _ <br /> � H.P. Sista Work Done <br /> Wee Oewuction O Wall DugrOvw SOakng Material glop 60') <br /> Depth Fier Materiel IBNow 60'1 <br /> TYPE OF SEPTI WORK; NEW INSTALLATION—1 I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system pernutted it public rawer is <br /> available within 200 feet.) S) <br /> t, Inauiataon wi11 aersv: Residence__ Commercial�, Other r <br /> Number of hiring units. Number of bedroom. <br /> ChNSCW of&W to a depth of 3 last: <br /> SEPTIC TANK Ll Type/MI Water ubka depth <br /> g Capacity-- No. Compartments <br /> PKG. TREATMENT PLT,Q <br /> Method of Disposal <br /> Oietartca to nearest: Wail foundation Properly Line <br /> 1 4 <br /> LEACHING LINE L1 No.i L.artgth of Nrer Total length/carr <br /> FILTER BED I 1 Distwa to nwnp; WON Foundation Progeny Line <br /> .` SEEPAGE PITS I I Depth Sin Number <br /> SUMPS l 1 Distance to nearest: WON Foundation <br /> DISPOSAL PONDS Il Property Line <br /> I hereby catrfy that I haw prepared this application and that the work will Ls done in OcMdancO with San Joaquin coca <br /> rules and repuidtions of lite San Joaquin Loi health District. q mY adetartcer, elate laws.end <br /> Hare owner,or k w*W 1119OM'S Signature canilia the following:111 certify that in the pwfamance of the work for <br /> wil-h dw permit is employ any personal such eertrer as to berate Subject to workman's cornpensation laws of California."Contractor hiring ora rub contractirp ori l <br /> lure <br /> tion laws ofCOrtifies the California."I certify that in the peAormartce of the work for which thus permit b issued,I shay Ompby Persons 111 IN- to workman's ootttptltae. <br /> } The applicant ear call requited inepeetiae. <br /> } Complete drawing on r <br /> i Spred an �� / <br /> Title. 9 P•� <br /> Darr <br /> _ FOR D€PAR NT USE ONLY <br /> Application Accepted by <br /> Data — �� Q <br /> b At". <br /> Pit a Grout Inspection by Date 46 Final IrtspeeNon by <br /> Date <br /> Additional Comments: — <br /> L1 Stlt 466-6781 LA-,di 360.3621 O Manteca les+ <br /> Tracy <br /> Applicant Return alt copies to: Environmental Health Permit/SOrvitea 1601 E. HatNton Ave., P.O. Box 2008, �.k., CA 96201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED ey <br /> i DATE PERMa,No <br /> EN 11-z.Ulv ��, /O C �' >�'NQS a- -- /_T6 —7)1 7 q <br />