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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZE. TON AVE- STOCKTON, CA <br />Telep' hone (2091 466-6781 <br />PERMIT EXPtRES 1 YEAR FROM DATE ISSUED <br />(Complete in TripficaI6,) <br />iv for a permit to construct and/or iri'statl the wn,k herein aescribed� This awicalion ill", <br />'�Aq uIrA <br />ioof rhes Sat) J <br />or sewage or No, 196-2 for we"P"MP and the Aul"s and Regula'ns <br />s meby malt to the San Joaquin Local Health Distr <br />at, joaQIiin County 0, dinance No� 5,49 f <br />,lace in compliance with S <br />local HeWw- <br />City Lot S*tzt PM <br />Job Address -11-x <br />Phone <br />Address <br />Ownw's Name <br />AddreSS <br />7--cSTRIUC' ION <br />t y PNEW WELL WELL REPLACE NT 01 HER D <br />. OF WE! L'PUM: IR L <br />I-- — --L --- PUMP INSTALLATION L SYSTEM EPAI. SAFLO PROP. LINE <br />DiSTANCE TO NEAREST: SEPTIC TANK SEWE 'NES DSPOL PITSiSUMPS <br />FOUNDATION E LL OTHER WELL <br />C TRUCTION SPECIFiCATtONS <br />INTENDED USE TYPE OF WELL PROBLEM Afl�� <br />Dial of Wen Casing <br />Manw <br />�c; :ia, of It Ex"Vali,nn <br />M Industniti LJ Open Bottom <br />C, Gravel Pack 0 Tracy T Yoe of Ca <br />0 Domeslic" Private Type of Grout I <br />171 othor r, Delta Depth of Grout at __ IN <br />j-, Public surface Seal linslatia y <br />,5 1 kiludlion ,,,-„y,Approx. Depth I e Wor$L'Done <br />Repair work Done f.-� Type of Pump — I <br />Well Destruction ClWell Diameter Sealing Material (top 50'1 ---- ., I I <br />Depth Filter Material �'Selciw 50*) <br />.. .. .. .... S .11,11, 1 "I'll 1 11 tUCTION I JNO 4ePtic sistlifn 0erm'ltetl 11 Put” sewer is <br />YPE OF SEPTIC WOR NEW iNSTALLATiO 'i REPAilth%DDITION available wt, hin 200 tePt <br />Installation will Serve: Resklence Other <br />of bedroom <br />Nurnber Of living units: ----L Numbe W3161 table depth <br />Character Of soil to a depth of 3 feet: <br />No, Compartments <br />Capacity --L <br />SEPTIC TANK n rypimfg - - Metht-d of Disposai <br />PKG. TREATMENT PLT. 0 l I S foundation Property Lin i <br />Distance to __ <br />to nearest: Fou <br />7— . ...... <br />LEACHING LINE C, No. & Length Of 40" topony Liew <br />FILTER SEC tD Distance to nearest: Wall _4�0 foundation <br />Si2a Number <br />SEEPAGE PITS Well 'Foundation property Urm <br />SuMPS L' Distance to nearest: <br />DISPOSAL PONOS 2 the wolti vAll be done in "cc tdance with Sap jo.,quin county ordinances, state laws, and <br />I hareby certify shat I have prepared this application and that <br />Local Health District. in the performance of the work or -hich this permit sued' 1 shall ?WA <br />rules and regulations Of the San Joaquin a <br />Home owner or licensed agent's signifitutO certifies the foaow'n. "I cordly ithansabon !Jws at CalifOrKa.-- Cor%tt;,ctcrt1s hiring or sub-contr3cting sign ture <br />employ any poison in such manner as to become subject to workman's COMPO issued, I shall employ periSiO.Ns subject to wafkMan's componsa- <br />cand,06 the fojoWinq�. 411 certify that in the oarlor-an--d Of the work tot vvh'th this pw(r'it is <br />bon laws of California." revere side. <br />The applicant must call for 34 required ' i spoctions. amplate drawing On tev`16 Date: <br />Titus:! <br />Signed X--CSL��l ENT USE ONLY Arad Lb <br />ApplicaMn'Acceptad by Data <br />Dat <br />�� <br />plt at Grout Inspectionon by Calls Final inspection tl <br />A4ditional Comments: --- <br />, 0 r. Lodi 3W3621 <br />- Stir 466-5-781Ik_ <br />C) Manteca M-7104 [,] TracV M-6385 <br />1601 E. halafton Ave.,AvaP.O-P�O- Box 2009 CA 95201 <br />Appgegn, _Return all cWies %o* Environmental Health PermiIt/SWViC`aS <br />- <br />CK 9 <br />AMOUNT VEM11TED <br />— <br />RECENEO By <br />0ATE pERM11 NIS, . <br />FEET PUNT 0UE <br />CASHaJi <br />-AEV <br />2 zo <br />