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<br /> •,� T . '' ," APPLICATION FOR PERMIT ,
<br /> s "., SAN JOAQUIN.LOCAL`HEALTH"D151'RICT
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<br /> +�'� 'z,. r 1601E HAZELTON AVE'; STOCKTON, CA `� c
<br /> '� h F eph a{2091 466-6781
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<br /> '��° t�; s �y* PERMIT EXPIRES 1rYEAR FROM DATE ISSUED s
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<br /> ` Apppeatitirl:&hera6y made to tht♦San fottquin Local HaaiM District Tw:a permll.to conatruc!arM:or install tfre.work herein described Thfe asrptleatbn Ir r -, z 3 a�
<br /> " �'rrnada m compliatxa wrth San Joaquin County Ordinance No 643 for sewage or o.1862 for well(pump and the Rules and,Ragur7timrs of the Sun Joaqurn � ;
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<br /> t„y, .Joh Address1. r�r � _- G•ttY Lot$r=e PM r a c {
<br /> .::" yalrM'""� , kh[ 1�EJ fLr !~RS Addre3/ O'+� J 9� ,�
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<br /> r.`�-> Ccntracta dress r' tw License ffa . 2. ,s ,
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<br /> } TYPE OF NEIC7P[JMP .',.tx p Nf Vy WELL:Q WELL REPLACE :Q DESTRUCTION C] r , y . s'L Q, ' ,»s .
<br /> { ' r t PUMP IH5TALLATIOr.N'C1L.
<br /> f ' `SYSTEIIr:REPAIR'D s l° xr
<br /> -4� OTHER:❑
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<br /> ' T, ' CE'T'J NEAFIEST-SEPTIC TANK SEWER LINES ,DISPOSAL FLD PROP UNE `y '- Y�t� 6�.7 .i t
<br /> T '�,r[ r. r dam! FOUNDATION J "AGRICULTURE W LL' OTHER WELL PItS/SUMPS '1� t�
<br /> s �� iNTENOED USE -, :TYPE'OF WELL PROBLEM AREA CONST8UC710N SPEC(I kTIONS ; r"F § 4�� `
<br /> I 1. p Indgstrwf '� U Open Bottom 0 Manteca Drs of Well Excavaw Dfa.',of We74 Caairrg l �' � I
<br /> r Q t7ornatllle/Prlvaeak GI Gravel Pack f rz: D Tracy Ty;•e of Casl r a 5 r Specrfrr-crena; Y ,'��{,i
<br /> rs�ra I'i Other Ci Delta Depth of Grout Sent r Tsps of Grout x Sa �� ,
<br /> ^w$M fix [ 4 a - :, .� i a, tic' ' fix"
<br /> `tet i; 9KW H,(�' ' Apprax Dept I'I Eastern &..dace Seal installed by J
<br /> �r` p ,_�. h,rfcYAor`fe `d. Type of Pump H P ._r State Wq lc Done a _t
<br /> �t Wap Desµ lona,°0i!r We11 Drarneter Sea�ng Mi terra{ltcp 501 �jj t 1.3 � u
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<br /> { , z r '` oep>n Filler Matenal l" , w 54'1 s "
<br /> u�i TY.PE"OF SEPTIC±WORK'-, NEW INS7ALLATI 1• a AIRI.ADDiT10N - DESTRUCTION l 1 1No sept system permitted if public Mwar rs r i' �, Tr', �°""
<br /> 4 Y + 4! a+raiabla within 200 feet 1 4 `
<br /> r q ttrtntlatlon uvea serve. 1.tdeit a Commercial.,,`Other_��__ _ t�p�` �G+ `�L�Ir1 i �•.•CSS� , z �'1
<br /> Namber Of Iweng uf4 Number Df bedtaoms j'`{ , F{
<br /> [Character. depth !: F Water table depth
<br /> 1. �^=rl���PTIC'TANK Of Capaaty _% .,No.Compartmalr sR t
<br /> *TREATMENT PIIf d . .,.1 ..,„" Ma..tiod of Deposal
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<br /> a ' r Distance to"nearest _ Wall.- foundation Property.Line 's z t'
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<br /> No ff Length of.nes Total length/sire t
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<br /> FiL + ❑ "Distance to nearest `� Well Foundation GU Praperty.Una '� U i
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<br /> ' 'SEEf'AGEtPl7 m r„ . ate.,'.._ Siva' Numb_ar .-.
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<br /> SUMPS L Distance to nearest well Foundat;on %Property Lina F z
<br /> + DISPOSAL PONDS :'s ..Q :. E v ;" .
<br /> �I hey_"rxrtify tr.at_1 have prepared this application and that the workwillbe done in accordance with San Joaquin county ordina{rces state laws and , - + -s, }
<br /> 'rides'and regula"..a of.ths,Sirrdoagiiu►katal Health District, . i
<br /> `,Moore owner... licensad'sgent's srgrtalure Citifies,the following."I certify that in the periorrnance"of the work for which his partrrit Is rssuedI I slta8 riot =
<br /> erripipy'ariyYperson in such manner asp�Amum a subject to workman's compensation laws of California."Contractor's hiring or salb-controcting srgrnttira N`� � _
<br /> c8!dfies'the.foiowbv:.'I certify that,n:ne performance of�t(he work for which this permit is issued I trhtlll employ.oaraarrs subtect to workmen's compema- + ,
<br /> 1 txin laws,oi Lalllomta:' t >*. I:.��� , _,,:.`a ,- -.t - ,14 tit '.
<br /> TTI-applicant cell for aur 1 tans'Gampleta"drawing on revs srde. '- ;, ` p/ c ` '
<br />} x Tub. /%i'�i�l Data /r`? .Q* x r ;,
<br /> �:, FOR DEPARTMENT USE ONLY _1�— O ' 3� 5*
<br /> C�lwa �Yr,�. i _ s „� n
<br /> 1,1,1111 prpprcatio Accepted by Date Pram ; ,
<br /> Prt a Grout inspactwn b Date' Ftnel inspection by + Data .1 a^I
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<br /> Addipplai'Cornments r.:—�rl.o—,.Lt. � �•f I i ",
<br /> f r ❑;S* `4IM-M1 O Lodi 3f 3631. ".Q Ment�ecs 82.1'-7104, . Q:Tracy 83&&'!85 r r 4
<br /> i Apptrce+lt Ratum atl copies to:Enwronrtrental F!eatth Permit/Services t601.EL..:-Ha:eltan Ave.,P.O. Box 2004,Stk. CA 95201 , 1. f r
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<br /> FEE ,AMOLfNT DUE 'AMOUNT nE7JlITTED CKs RECEIVED BY DATC -PERMIT NpLL' r s
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