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" Fa <br /> FtR <br /> - k _ .. r +Y+.. •h". t ,arc. E A <br /> 7 .4� <br /> APPLICATION FOR FILE Copy <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAMTON AVE., STOCKTON, CA { <br /> Telephone (2M)4W-SM y <br /> P; <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) - <br /> ',rn;iration is hereby made to the San Joaquin Local Health District for a perm*to construct snellor&MA the trrOrk treraht dlsClldad.Tri apPfl W0"la" <br /> 7-.,rip in compliants with Sen Joaquin County 0.6nai No.549 for sewage or No.IBM f w wet/PLOP and dna Attlee w d Al-tiledri of Idle San joevi n <br /> !-til HeAlth District. ; <br /> f _ob Address _City .�!! Lot Sho PM bn <br /> Corner's Na t Address ` Pllalr w.a"fir: <br /> antrattorAddress r 01,2 "*t =5— & ia <br /> -YPE OF /PUMP: NEW WELL 0 WELL REPLACEMENT DESTRUCTION 0 ;'t <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER <br /> Oi STANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL.FLO.------ MW.LINE 't A <br /> FOUNDATION _AGRICULTURE WELL OTHER VYELL PRSISUli11P3 <br /> --INTENDED USE TYPE OF WELL PROBLEM AREA CORISTRUCTION SPECRICATIQNS <br /> Industrial ❑Open Bottom 0 Manteca OIs.of VM Eitcaratbn Dii.d VMeB Cwhq` <br /> a <br /> Domestic/Private 0 Gravel Pack ❑Tracy Type of <br /> <:I Public ❑Outer 0 Delta Depdt of Grout Sad TV"of Gfflrt 1" <br /> `1 Irrigation __Approxi Depth ❑Eastern Surface Seo 1 by <br /> Repair work Done 0 Type of Pump H.P. StM Work Dona :_i ` <br /> tivell Oestructlon 0 wen Diameter Seating Mstarfel(trop 5D7 <br /> Depth Filler Mslarw IBeronlli wl <br /> F TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIRlAODfIION d DES UCTIOIi[]_INo fe C sysLelm.Pwn�Md.i!Pttbie issue► <br /> hrrAhin 200 hrt.1 ,� <br /> installation will serve: Residence, Ca': Outer -` <br /> Number of living unite: Number of WEW table ftffi 12 <br /> Character of soil to s depth of 3 feet: In <br /> SEPTIC TANK 10 TypelMfg CaPtrclty <br /> PKG. TREATMENT PLT.❑ 1 r MtrAhod D + <br /> Distance to nearest: well - Foandstlon. Ptapsrty Lhw--,/At&t-- <br /> oil <br /> l-EACHING LINE No.&Length of Rnas D / oW langthi 4 <br /> FILTER BED C3 Distance to nesreat: Well-«Q— Fatrndedon Property Lkwf' <br /> SEEPAGE PITS Depth _�'�_. Size Nurrtbsr., <br /> j SLIM"S 0 Distsnoe to nearest: wenCd i Foundsdon_-7-At .. PooPaNy Lam 4= .- <br /> DISVCSAL PONDS CI <br /> I hereby cerL.'y that I have ipwo d this aPPlicaift^and* t the work Vv@ ba done M aCC 1 0-h0a with San Joagahh 009011h OrdhnarnOM:aillft Morel, <br /> I <br /> IU lee and regulations of the San Joaquin Local HP ri.h District. <br /> 9 ;s Home owner w Roensed aga Ws signature OsrtlNes 00 foaowhq "1 osrtlly sR Li totoparlsemarrt+a of dodowok for whk�r tNs PWM Yrtlyd:141ud notF v <br /> employ any psi am In such nwwrer as to become au6lxt to worknan•Conrp4etar1brl 6M d Csaloria"Carrtraolrils fn`YtQ a>ttraoorttraetinY 4lorrabrli t <br /> certifies the following:-I cwft that In the perfonimms Of 1110 wok fpr which!Iris pwn*hr 1100004 101011111 SHOW psrsors sublse t ffi worknrart'a aan�afrF.i" �.,i'' <br /> tionlows of Cali Is." <br /> The appilca m ae kwlpectfons.Complete dowing an ramem sldh. a <br /> Signed .�_� Tide:__ Date: f y g <br /> FDR vepAmme t'Un ONLY t <br /> lication Accepted by Data ARM z; <br /> Ki <br /> l r Grout Inspectlon by ow-- Oats�1e1-tL-by�+ Fbw MypM by a Date <br /> Additional Cammente: ; <br /> r Stk AMMI © t .!I 30-Ml 0 Mentem 823-7104 E2 Tracey amm <br /> A phlicant- Retam all copies to: Enwkorwroom l Haahh Permit/Services tW1 E. Nw Ian Ave..P.O.11110111 2M,6th..CA V= <br /> w <br />[ Ffe AMOUNT DUE AMOUNT REMITTED N Rttt:l111LIb Cy OAT; rrtlbl/T 110. <br /> INFO <br /> 1 4�i4 <br />