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Rav(A w <br /> APPLICAVON:POR PEAMIT <br /> SAN JoAaWN 100AL 14ALTH WSTAICT <br /> i6mi P. HA2ELtON AVE., 'STOCKTON, CA <br /> feldo ibfie OD91) 4W-SAI <br /> pel#MIt exhll#ES 4;AAh EI#OM bATE ISSUED nn <br /> ,, , iCdlmplete in Triplicstai <br /> U <br /> Appilcolon le Iwoby m1dj to the San Joaquin Lova)Health District for a permit to construct And/or install the work r application is <br /> mark in oothWitcs with SM JoadUhi C61inty OtAhSh6d No.Be Ito 6ev160 of Nd: 1862 for"ll/punto and tho Rules t San Joaquin <br /> Local Hsaith bistdct. t <br /> 72t0 t �j <br /> Job Atm City .� Lot St#N_ <br /> Ownee$Name Addresl phone 2 <br /> Conlracl3l <br /> s3 fa iceese No.—Aoq�`♦siSo`ne <br /> Ump:' <br /> Rl ta1r13 a PUMP INSTALLi� ON d+ ' SY REPAIR ❑ OTHER <br /> St. 6 TANK ► S S DISPOSAL PLD. PROP. LINE <br /> Rt iN FOUNLIAtt$N ICULTURE WELL OTHER WELL PITS/SUMPS <br /> Sf Olk type Ar. khool emAALk--;a" <br /> ❑HtdtrftiFef ❑Ow 861&; t] Manteca Die. of Wei Eiccavatton Dia. of Well Casing <br /> ❑ /firhrat! 0 Gravel Pea © Tracy TWA of Casing Specifications <br /> ❑ Ch Other k fl dielta Depth of Grout Seal Type of Grout b#—hh t!h g1r <br /> lnipatk* j, J-►/klApprolt' booth I I Eaitem Surfdce goal lhstallsd by - <br /> Repair Work Dona b Type of Pun* % HA State Work Done _ <br /> Well Desttuttkln i ❑ Wad Own" Sealing iufatboal two bol <br /> lupth - POW MatWol 10ek*6001 <br /> TION 1 I INo septic system permitted if public sewer is <br /> .03 <br /> available Within 200 teet.l <br /> linatel atloh#A fdnra: Reaida00 i: comw4rclal— other <br /> Nurnbdt 61 1lvktg unke: Number of bedrooms <br /> Character at soh to a depth of 3 feet: - h <br /> SEPTIC TANK ❑ tw6/Mfg ^; Cbpaelty <br /> PKG. TREATMENT PLtI,❑ Disposal <br /> Dlatinn to tttillW1 Welt P6UhdatW Lkte <br /> E <br /> LEACHING LINE ❑ No. A t_tlftpth th himim _ - Total length/size <br /> FILTER NED 0 bitltilr►tsli to ltaA"i ' we# Fouhdawh Pi,60 y Lim <br /> SEEPAGIE PITS ! j I I Otiplh k alit _ _ humbar <br /> SUMPS .L7 blatArital to tteeF is Nia9 twrtdation 0*60"Line <br /> DISPOSAL PONDS ❑. <br /> I hereby txtrift that I have WeWM dQ**MtrilMh And that ihO Worst Will bA ddna in accordance whh Son Joaquin county ordinances, state laws, and <br /> rules and MWAkiona of the San Jhagulfl LOW HUelth b6trlet. <br /> Ho"t1M W dr""d egafit'f flbl*hA tx"tlsi foMou4irtgi j'l tM*#W iR 0*performance of the*ork for whkh this pmM is issued, I"not <br /> t+ntpkty airy ptlreort in At""Aw*ii id b&"*tltt*&to+iNotk"h's 6ortipanUtion left of California."Controctor's hiring or sutreonttaetittp signature <br /> CAN#4 following.-1 bk*this in 06 of tltf worst hx ii hlch thib own*is Issued,I shah unploy peraarts sitbiect to warkntart'f convenes- <br /> Son le"of Callforflie.". . t <br /> The applfCettt 60 lot ell mq#w Colitpibfil durst"on ravariit tide. <br /> slenw Date: q—(0 <br /> �4 1illilfs � Nt Us t ONLY <br /> rye e�r it 4�I:+1►rt�A �I tai t�►� : <br /> Appkod6n Adceptad tW Date '~ Area <br /> f a. <br /> Pk dr(snout INipecliofl by € � � j Date Rhe!ldapaetion by Date <br /> Addli.f/7pf Coriv*ldirft: k <br /> ❑Stk 4W M1 ' 0 Lodi 10-31121 ❑Mthftd W-7104 d Tracy wo-ma5 <br /> Applicant- Return ON 66pl i to: I!Avk6WMrAO1 Hielth PMmk/SlAvicsi 160) L Ntitetton Ave.. P.D. Sox?OQl), S*k. CA Wi201 <br /> O AMWr bMOU <br /> UE ' ANt 1`19M tEfl a 111#CUIVtD UY DATE PERMIT'NO. <br /> r tEH 1121 dlev.t i w E 4�1 26 <br /> EN 14.21 <br />