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I— <br /> APPLICATION TOR PERMIT <br /> 'COQ SAH JOAQUIN LOCAL HEALId DISTRICT <br /> IbOI E. HAIELTON AV(.. STOCKTON. CA PERMIT N0. <br /> ielephdne (id9) 466-6781 DATE ISSUED "� iI <br /> PERMIT EXPIRES 1 TEAR FROM OAT[ ISSUEO J l i <br /> (Complete in Triplicate} ;� !i <br /> A40110ca11106 Is Mnbv mode to the San Joaquin Local Health Dlstr1C9 (Or a permit to construct and/or Install the work herein �S <br /> deserib". This opplltetton is mat In Copt Hnce With San Jo+gwin County Ordinance No. $49 for sewage or No. 1662 for well1pumv <br /> And Lht Wlet1�&Ad "via Ions of the San quirk Local Health District. <br /> Job Address dr v Subdivision Name _ y <br /> Ga►er's NaleneVAI IL Address Phone - 071 _ <br /> Gontrlct4rY6 h4lele LICMif No. Phone <br /> TY►E OF WELVPIAIP YORK: NEW WELL © WELL REPLACEMENT © DESTRUCTION[� 4 <br /> NMP INSTALLATION C] SYSTEM REPAIR OTHER <br /> 1 <br /> P.13?ANCE 10iIEaiAESt: S[PTIC IaLMx SEWER LINES DISPOSAL FLD, PROP. lin[ — eJ <br /> FOUIOATIOM AGRICULTURE WELL OTHER WELL _• r PITS/SUMPS i <br /> LAMB(* USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECtFICAI'IONS � } <br /> IndWsirial ❑open Bottom ❑Manteca Dia. of Well Eaca cation <br /> IZ MALIC/Private rl y .A <br /> s+C�TT..JJ��.'". Gravel pec► Tracy Dia. �f Well Casing _ li <br /> f'irYllc'"" �jOther ©DOIu ;I <br /> Erriyatiec. Type of Casing . <br /> ©C.thodle Protection q�jp�A� ❑Eastern Specifications <br /> []fwoprgstcal Depth of Grout Seat _ <br /> other TYPO of Grout _ <br /> SuFface Seal Installed by r w <br /> i4pair Yore Oona T 0f H P a <br /> Q ype Pi+mP Siete Work Done <br /> well Destructloh O Well Oustater Sealing Material (top SO^) <br /> �>kPth filler Material (Below 4.) <br /> { TTPE OF SEPTIC WOR;: NEW INSTALLATION REPAiiVADDITIOB U (Mo septic tank or seepage pit permitted if pwbliL sewer is { <br /> ' • available within ZOO feet.) <br /> Installation Will serve. Rest Commercial _ h _ <br /> de^Ge ,� Ol rr <br /> IMrner o/ lirlrp units; _ Nuber Or bedrooms � 9W _Lot size 1 <br /> Character of soil to a daoLb-of 3 feet• B Water table depth1. <br /> SEPTIC TANK Type/Mfg CaF city No. COrpartm+ents <br /> P96. TREATMUiT PLT. C3Type/Mfg Capaclt; Method of Disposal <br /> SEWAGE SYSTEM d <br /> DESTRTION Q Distance to newest: Well Foundation _��� Property Li <br /> UCne <br />}St LfJLCHLatG L1alE ho. s Len9T.h of lines Total Itnath/siie <br /> L. FILTER BEO Qlstance to nearest: Well Foundations A, Property l?�_y ' <br /> SEEPAGE PITS Oept1 It;e F NL•aoer a <br /> SLAPS U Distance to nearest: Weir Foundat ton �`�-+ �PmPerty Line �� �?? <br /> l.. <br /> 'DISPOSAL PONDS ; <br /> 11�P1Y.lr ED <br /> I hereby certify that I have prepared this application and that the wort, will be done in accorl:snce with San Joaquin county •� <br /> ordinances, state laws. and rules and regulations of the San Joaquin Local Health District. E <br /> home owner or licensed a ends sspnature certifies the following: "I certify that in the performance of the work for which this <br /> persist Is $$sued I shalt not employ any person in such manner as t0 became subject to workrani dispensation Iaws of California.'; <br />} Contractor•$ hl n9 or sub-contract}ng signal t certifies the following: •1 certify that In the performance of tht work rpr wh14h <br /> 7Z. this 1. 1; is ss ed, I ah li emplo own subfect t0 mor nls compensatlen laws of California," i <br /> The appl 1 f all i do S. Camp tr on revrrse side. <br /> f S19ned z Title: _ Date: .0� <br /> T USE ONLY L% I r— <br /> Applitetion Accepted by Area t Ste 166-6781 <br /> Q� Additicnal,ZO�ents: Lodi 369-3621 <br /> ///1 ' Pit or Grout Inspection by te Mante.a 8T3-7104 <br /> t <br /> F,. ?��, Final Insnectian by _ Os to ! 2 —f� 0 Tracy 83:,-6385 , <br /> P11L awtr- Rwtwrn all COPlem to. tnvironowntat low— Prf+N t/Serrtcn 1601 E, iiaselton Avv.. P.O, 'has 2009, ltk., CA 95201 <br /> iii BASE AMDUII CDUE l AMOUNi kLMIIILD RICCI= 8Y 1LATE PERMIT N(.�� <br /> o <br /> 10/82 500 <br /> LN 17-24 itEY. 10/B2 y <br /> Ia-26 <br /> } <br /> f oar„ . .:�• a .. . <br />