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( <br />Job AddrvM <br />Owner's Name Phono <br />4" <br />UJ <br />E <br />Capacity. <br />Distance to nearest:Wo* Foundation <br />We* _ Foundation <br />Foundation <br />The caMfora* <br />Signed X.TMo: Date: <br />DEPARTMENT <br />Application Accepted by Aroo *!L. Dat^^ <br />Pit or Grout Inspection by Final Inspection by <br />AMOUNT DU€AMOUNT REMfTTfO RECEIVED RV DATE PERMIT NO <br />X o/>3 l?H-Uix <br />Sire <br />We* <br />i. of Wo* Casing <br />LEACHING LINE <br />FILTER BED <br />FtC <br />INFO <br />Total length/sL»___ <br /> Property Line <br />Number <br /> Property Line <br />_____Water table depth _ <br /> No. Compartments <br />Method of Disposal <br />Property Uno <br />. rn is-jr i«rv io in <br />»h u on <br />Depth <br />Distance to noettst: <br />No. E Length of rnes <br />Distance U nearest: <br />-^7 <br />Date <br />F <br />A <br />0 <br />J <br />b <br />INTENDED USE <br /> Industrial <br />CjA^tomestic/Private <br /> Public <br /> Irrigation <br />Repair Work Done <br />We* Destruction <br />Phone <br />DESTRUCTION <br />OTHER <br />PROP. LINE <br />pits/sumps <br />Additional Comments: _________________ <br />C Stk 4094781 Lotfl 388-3821 Monloco 823-7104 Tracy 838-8386 <br />Applicant - Return a* copies to: Environmental Health Permit/Services 1801 E. Hsrelton Ave., P.O Box 2000. Stk.. CA 96201 <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 4664781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) • >c.ni <br />San Joaquin^ Local Health District for a pennit to construct and/or Install the work heroin ^ejiVQy-r^^liicpiloii is <br />oguiations df/tisan Joaquin <br />Cor <br /> pm <br />Installation will serve: Residence Commercial Other <br />Number of living units: Number of bedrooms <br />Character of so* to a depth of 3 feet: <br />SEPTIC TANK O Type/Mfg <br />PKG. TREATMENT PLT. <br />AGRICULTURE WELL <br />PROBLEM AREA <br />Cpfaarneca <br /> Tracy <br /> Delta <br /> Eastern <br /> H.P._ <br /> Sealing Material (top 50"I <br /> Filler Material (Below 50'1 <br />DESTRUCTION C (No septic system permitted if public sewer is <br />available within 200 feet.) <br />o*1-* y <br />SEEPAGE PITS O <br />SUMPS <br />DISPOSAL PONDS <br />w* 0* <K>n« In accordance with Son Joaquin county ordinances, state lews, and rum Rnd reoulRfions of the San Joaquin Local Health Otethct. <br />Home owner or llconoed anent's aigneturo certifies the foeowing: n certify that In the performence of the work for which thia permit is hauod, I she* not <br />non laws or caRtonua. <br />Inspections. drawing <br />^iSi <br />License No. <br />WELL REPLACEMElf <br />SYSTEM REPAIl <br />SEWER LINES . DISPOSAL FLD. <br />OTHER WELL <br />CONSTRUCTION SPECIFICATIONS <br />Dia. of We* Excavation // y <br />tYP« of Casing----------------fiKL/Z5U,ySpeclfleations <br />Depth of Grout Seal Type of Grout <br />Surface Seal Installed by S <br />— State Work Done <br />cit^aWz^1 Lot Sire <br />714 /j)- l fr&U'kk.y'y <br />TYPE OF WELL <br /> Open Bottom <br />(JKiravel Peck <br /> Other <br />Approx. Depth <br />Type of Pump <br />We* Diameter <br />Depth <br />TYPE OF SEPTIC WORK. NEW INSTALLATION REPAIR/ADCITION <br />Jcrs-^> <br />L- <br />Local County Ordinanca No. 549 for aawage or No. 1882 for wall/pump and the Rulee and Roguiatione <br />Shu. bi(j 4/nu. ✓Address <br />Contractor's Name JP <br />TYPE OF WELL/PVMP: ff NEW WELL ' <br />PUMP INSTALLATION <br />DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION