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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone IM9) 468-$781 :PERMIT EXPIRES 1 -YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made In the San Joaquin Lacai Health District for a permt to construct and/or instal the work herein describer)_ This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. IBW for wahi pump and the Rules arid Regulations of the San Joaquin Local Health District; f Job Address .Y..1. f62 NRS Lana City __ Lot Size PM I hereby certify that I have prepared this appiltation and that the work will be done in accordance with San .fbaquin county ordinances, state laws, and rules and tegulab om of the San Joaquin Loral Health Oallrict. i ' None owner or kcermd &gem's 4w*hma cadMas Ow tDdotev+g: "i earthy that in the performance of the *v* far which this pwrW is istiusd, I shah tart etnpkhy any person in such as to become subject the workman's ci>trt,pin"tio. Iahvs of California," CormtiaaWS hh*V a rtttb�ottb�acting signature c, ies the f>�. "I that in the perim� of � work for wihich this prerrrmrtt is }Ssusd, I empby pawns �t to workrtraNt'S compensa- tion Iowa of Ca iforma,' The applicant must,, umu r r `sed ktspact . Com plate drawkV on, reverse side. signed x Tido: >Rkpr. _ .,t. rr gr; ii8l07190 t Application Accepted by Pit of Grout Inspection by AMkin A t`_fVn wn►A' C�P] POW DEPARTMENT USE ONLY Ci Stk 4664791 i tt t.adi 3ft-3mi 0 Mwttecs M7104 n Tracy i Applicant - Return at copies to: EnvirttrhrtxrnW HtrMM Pe> /Selvicbe 1ADI E, Hoa ttrt Ave., P.OStec AM. Stir . Cao 2=1 FEE AMOUNT DUE AMOUNT REIMITTEO AW.M #O IAV OATt PERWT` NO. aNFO awr4ta♦ LL 0 , owner's Na wast t -fti I _._ HOM PAIt Address 11662 N am In _ Ph&* 17754 N. HWY. 88 Contractor Q,&trjn01_ AdthessLQCke Ford. Q. License No. N2911 — Ptwna -Z?7- 5 48 TYPE OF WFEW-Pp-, MEW WELL 0 WELL REPLACEMENT Ci Des Ute PUMP INSTALLATION 0 SYSTEM REARXI OTHER 0 DISTANCE TO NEAREST: SEPTIC TA;NX ......... ._ SEWER UNFS _ `h ; DISPOSAL FLM— PROP. Lt"-- FOUNDATIO14 AGRICULTURE WELL OTHER WELL _ PiTSlSUMP$ INTENDED USE TYPE OF WVLL PWOLFJAAREA CONSTRUCTION SPWFiCATiONS o Industrial o Open Bottom- Ci mantecs tale. of Wed Exckvaion ois, otWeh Ctukrq L; DomesticlPrruate U Gravel Pack i 3 Tracy Type of caiI I tsiaetNic *.s I"- Public i:? Other m n Bette DibptKof Growl Seri Type of Grout _......._. 7 I ' lrrllation .._. Approx. Depth t I earn Sadatce buW§pd by Repair Work Dote 0 Slaxe Wttttt Dxtrp Rmv4W 3W In"�� Type of Pump H.P. r rHP Wag Destruction 0 Well Diameter' Sealing Matardltop SWI Depth Filler Material TYPE OF SEPTIC WORK. NEW INSTALLATION ('I REPAIR/ADDITION I I DESTRUCTION;1-I (No sOft syste n mhhitted it public sewer is 2Yeet.I * availab within " _ . ,, rwahation %&A servo: , Resit�rmh as ...... , CgnwtercW .......... Other Number of living units: Nurnb�; of badrooms r Character of soh to a depth of 3 feet: Waley table depth. SEPTIC TANK 0 TypelMfg Catptt Irs , , 'No. Compartments _.._.........._ PKG_ TREATMENT PLT. n ' it: of DiaprmSal I Distance to nearest: VM artt deiirirt Pra(teAv Line m t LEACHIING UIE U, No. 6 Length of tines Tatar lsr�thisi� ` FILTER SED © Lkattanoe to nearetat: 14tSi1. �+�` rty Line SEEPAtiE PITS I I Depth Sins Number SUMPS Ll Distance to rte; Wail _ _ rP Property cwt DISPOSAL PONDS r T z I hereby certify that I have prepared this appiltation and that the work will be done in accordance with San .fbaquin county ordinances, state laws, and rules and tegulab om of the San Joaquin Loral Health Oallrict. i ' None owner or kcermd &gem's 4w*hma cadMas Ow tDdotev+g: "i earthy that in the performance of the *v* far which this pwrW is istiusd, I shah tart etnpkhy any person in such as to become subject the workman's ci>trt,pin"tio. Iahvs of California," CormtiaaWS hh*V a rtttb�ottb�acting signature c, ies the f>�. "I that in the perim� of � work for wihich this prerrrmrtt is }Ssusd, I empby pawns �t to workrtraNt'S compensa- tion Iowa of Ca iforma,' The applicant must,, umu r r `sed ktspact . Com plate drawkV on, reverse side. signed x Tido: >Rkpr. _ .,t. rr gr; ii8l07190 t Application Accepted by Pit of Grout Inspection by AMkin A t`_fVn wn►A' C�P] POW DEPARTMENT USE ONLY Ci Stk 4664791 i tt t.adi 3ft-3mi 0 Mwttecs M7104 n Tracy i Applicant - Return at copies to: EnvirttrhrtxrnW HtrMM Pe> /Selvicbe 1ADI E, Hoa ttrt Ave., P.OStec AM. Stir . Cao 2=1 FEE AMOUNT DUE AMOUNT REIMITTEO AW.M #O IAV OATt PERWT` NO. aNFO awr4ta♦ LL 0 ,