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ria <br /> i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE�TON AVE., STOCKTON, C4 <br /> Telephone 12091 4666781 k <br /> PERMIT.EXPIRES 1 YEAR FROM DATE ISSUED ,z '-- <br /> _. ..... _..- (Complete it, Tnplwmv) <br /> "Plu'"lme D Iwryby made la me San Ja.VUIn local Health D.bb.,for a telnnl In cave>Iu1[I dnd'Ur nv.Nll the work helm' de cntWJ TIMY appkcabnn n <br /> InJdY In I Iln.nlM 1111 WIIII j111 JIT.'We-CIIVIIIY Ulllnlallld N. WD IDI MWaee nl No Ila,%f VI W.i,W111111.1111 It.,14.10.and NdpVlahVlw UI itw San JWnVlll <br /> LU11111Ya1111 .11\Illll (� <br /> Jot,Address I// �+J_ e. 1P _ Lm Sled _ PM <br /> --- <br /> Ownel's Name /^��CC Addross �jf� �{�nunr <br /> 1 <br /> Carl for eM1�8�1Bd[r� Addless .vlI f�1a(l.CoJ� Llc ens• No.L LJ12j4)._Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT i DESTRUCTION 11 <br /> _— \. <br /> PIMP INSTALLATION SYSTEM REPAIR I OTHER O 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK _{���'/-�._ SEWER LINES _-� DISPOSAL FLD,c'�_ PROP. LINE <br /> _ < j K�/�-fOUNDATION �� AG_RI_CULTU_RE WELL ��_ OTHER WELL _ PITS/SUMPS ZnZ-# <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION mSPECIFICATiOH�k .4(� <br /> fQ Industnal �- Ci Open Bottom 17 Manteca DTs. of Well Earavatlpl _��_�_ U". of Well Calling <br /> Domestic/Presale ,Pki W Pack 1 I Tracy Type of Calling_ �!„�._� Sp r0l ataals g�1 <br /> 00 <br /> 1': Public 1 I Other 1 I Della Depth of Gloat Seel __ TvP-of Grow <br /> I Inlgalmn __ Apploa. Depth'�ssI�II Eaaeen I'I a Seal Installed by _ J_ <br /> Repay Work Done 1 I Type of Pump SE?t1_ H P. --- <br /> _ State Work Doles <br /> WeR Destruction 1.1 Wall Diameter _ Sealing Material Itop 50'1 <br /> Depth Filter Malenal IBelow 50'1 <br /> TYPE OF SEPTIC WORK, NEW INSTALLATION HIPAIR/ADOITION I I DESTRUCTION i I INo"Taal system onrmUud d public wwa u <br /> avatebte wollrn 200 fact.) <br /> Installation well vem <br /> same: Residence_ Cornnclal _ Other <br /> Number of kvdg units: __ Nul\per of bedrooms <br /> Chafxtw of suit to a depth of 3 feet: __- Water table depth <br /> SEPTIC TAW' Cl Type/Mfg CdPacny--_ No. Compeamemb, _ _ — <br /> PKG. TREAT MENT PLT.11 <br /> Method of Dlepoeel In <br /> Distance to realest: Well Foundation __ Pr <br /> - - -— -- —npenY Line <br /> LEACHING LINE Ll No.8 Length of lines Total length/sue_ <br /> FILTER BED -- I) Distanu: to nearest: WWI- Fountlatwn — — Property Lire <br /> 14 <br /> SEEPAGE PITS I I Depth -_Sim <br /> SUMPS t I Distance to nearest: Well Number <br /> __ Fountlatwn- _ Property Lire _ <br /> DISPOSAL PONDS I I <br /> 1 hereby comity that l have prepared this applicati7n and that the work wal be done In accordance with San Joaquin county aid:,tineas, state laws, and <br /> rules and regulabons of the San Joaquin Local Health D31nct. <br /> Home owner or licensed agent's signature candles the following: "I cenity that In the performance of the work for which this parent s Issued, I atoll mol <br /> employ any person.n such manner as to become sublet:to workman's compensation laws of California.-Contractors hiring or I _onustd, signature <br /> candles the following: "I cemfy that in the performance of the work for which this permit is Issued,1 shall employ persons wblxt 10 workman's compensA <br /> tion laws of Cautane.r. <br /> The appl. I I repui s Compete drawing on lovereesga. <br /> v <br /> Signed X Title: <br /> 1 L <br /> Date: <br /> FOR DEPARTMENT USE Of:l <br /> it <br /> C <br /> 1 <br /> Application Accepted by/ Data y- t _ A. 1 <br /> RI or Grout Inspection by ��r 1 Daze•'1' - k! Fire Inspection by DelaIt <br /> Aalallonal Comments: _/"� LaU/"�/, L11T - U y1 n.. r( <br /> v Su 96667e1 ❑ 3fi&362/ Mewtece 111217109 ❑Tracy 63556395 <br /> Applicant - Rmrur.,l as copra to:Envuorueental Health Pelwt/Som"s 1601 E. Heaslton Ave., P.O. Sol i00B, Sete.,CA 55201 <br /> FG AMOUNT WE AMOUNT REMITTiD --F:RECEIVED BY DATE PERMIT NO <br /> INt.: CASN <br /> .9a uM ury <br /> J. <br />