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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ; <br /> i6oi E -HAZnTON AVE., STOCKTON. CA <br /> TekivMrie(209)466-Ml <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> (Complete in Triplicate) Kx <br /> Appmcetion is henby rtwda to efts San Joe*xn Local Health DaInct fare permit to coratrtrct and/or kwo do work hanah dracraNK Tidy appmealfan iii <br /> mieftincompsonce with Sen Joequin Com'"Y Ordi wrtre No 5e9 far sevrepa or No 1882 fa vvsflJpump arvd the RuMa and(Mgrlatlwr of tlsa Sas Jt�agndn e ��. <br /> Local Health Dsvwt <br /> 4_ <br /> y .lad,Address Z `S �' <br /> Owrwe's Nona efd t Address <br /> l s ti i. <br /> Contractor r iMGress Z Lltense W 13 Phrane 4�i� <br /> t TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION L) rti5+r <br /> a !'UMP INSTALLATION ❑ SYSTEM REPAIR &--0' OTHI71 ❑ <br /> DISTANCE TO NEAREST SEPTIC TANK I SEWER LINES DISPOSAL FLD PROP.LINE <br /> FOUNDATIC44 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> �pr <br /> INTENDED VSE -T"E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑111(fust-101 0 Opus Eottom 0 Manteca Dia of Well Eaemilor DID of Well Casirtp <br /> arc/Private ❑Gravel Pads 0 Tracy Type o}Cuing specIfIcIrtiorls <br /> E3 Ptrblrc 0 Other r []Deka Depth of Grout Seal Typo of Grant <br /> ❑kngation /_-Apprc Depth/0 Ace Seel kataeed by 42 <br /> Repw work Done e Type of Pump H P State Work Done <br /> Well Destruction ❑ Wag DwYmner i Sealing Material(top 571 <br /> Depth Filler Mats W(Below 5V) <br /> TYPE OF SEPTIC WORK NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION❑ INo sapft sysam penn'ttad It p aft fewer Is A- <br /> ayslabie within 200 feet 1 ; <br /> a; Installation will terve Residence— C.e+trat Other <br /> E u <br /> of mber wvK+Q nits Number of <br /> Nuedrooms , <br /> r .s�' ! <br /> Characteret-of sol 10 a depth of 3 feet- Water Water table depth <br /> r ' <br /> SEPTIC TANK ❑ Type/Mfg No Co-Pertrrients <br /> MethodDef ia)osai <br /> ~ PKG TREATMENT PLT O ` <br /> Distance to neertrat wee Fpatdatloet Properly Line ` t r� <br /> r <br /> a, 1 <br /> LEACHING LINE ❑ No 8 Length of�Or— Total length! <br /> FILTER BED ❑ Distance to nm ek Wee Foundation Property Line �d <br /> r SEEPAGE PITS 0 Depth - —5i: Number <br /> ` SUMPS t ❑ Distance to near" Wee Foundation Property Lina <br /> DISPOSAL PONDS 0 <br /> Yy f fterebtr certirY prepared the on end that the work ail be done tar a[eordanoe with San Joaquin tx only ardirtenoss,stalls laure.arra <br /> midi ark ons of an Joogtm Local HORM DmtrkL +no4St e <br /> Florrte Or BGenled a aignrture oertit�ss the fogowtng "1 ow*y that in the Parformanoce of the work for whkh this parrdi 1•iterred.l ehrlf r tin <br /> p employ person In such ae t0 subpct 's compensation b"of Camtomh"Contractor s Inking or cab r�ortOtCHnp dPtattrrr+ Asn <br /> foearring 'l In work for which this permit is issued,1 sham employ parnons subject to workman's eartVWN& <br /> ;i tion of Ca6forno <br /> 7Rw an <br /> r= <br /> Title <br /> DEPARTMENT USE ONLYqQ0_ i- 'r " f _ •" • x57 <br /> � <br /> 4 Appf 011.AC�apt6d Area (� d-' ' <br /> D.4 k 177 <br /> 1 +. Pit or Grout hate _ Fixl IrnpsCik>rt by <br /> n ; — d r i tF r y a.y Ll r E <br /> r Additions!COmnwnta. <br /> ❑Stk 4864781 ❑LOCI388-31L1 ; 0 All 1 111711-710- 0 Traci/ $364M <br /> Applicant-Return all copies to Envkonmut d Fleeld Pern*1ServiM 1601 E.Hahslmn Ave.P O Oat 2008,SOL,CA 96m1 <br /> Vwl <br /> -- 1 AMOtA(T 011E AAt01JNT 1tEMl7TED FMCUM JiV '01111E PElwrftOova CASH <br /> '=��v,k` •bl 1?%IaEV t�rsY �a �O ����� 'r. r '•-' <br /> .h �4 �91�y t vx 3�M� l9t•.41�7 <br /> h <br />