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T' <br /> a - <br /> c������ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Q� <br /> 160. E. HAZELTON AVE., STOCKTON, CA <br /> Telephone <br /> PERMIT EXPIRES 1 YEAR(1 <br /> FROM DATE ISSUED <br /> (Complete in Triplicate) ,JV,•t(.lcOpN�'�'o� '1GE5 <br /> Application is hereby made tc the San Joaquin Local Health District for a permit to corotruct and/or install the work eraByWa�cnaed.This BPpacedon is <br /> made in compliance with San Joaquin Commy Ordlrnance tip,549 for sewage or No.1862 for wee/pump aM the Ruga sod Rcyvetions of the Sm Joaquin <br /> Local Health District. <br /> JOD Address _1�j✓ � �'- �-�d Ciry� �1� Lot Size.___�lPPMlik <br /> �`p <br /> Owner's Name Address 3 <br /> License No, <br /> Contractor 2�ZPhone � <br /> Add yJ/w TAO! Addrcss <br /> TYPE O`Ws NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION G , <br /> PUMP INSTALLATION R' SYSTEM REPAIR ❑ OTHER '❑ - <br /> DISTANCE_TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE _ s <br /> _ r <br /> FOUNDATION _ AGRICULTURE WELL __ OTHER WELL__ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSyRUC"rioN SPECIFICATIONS k r <br /> ❑ Industrie{ ❑own Bottom G Manteca Dia.01 Well Exuvalen _ Da.of We.;Casing <br /> 2�DorrresheiFwate ❑Graval Pack G Tracy yp0 T - = <br /> Of Cfleing $peCdk:atipre <br /> M Punic n ONcr - ❑Delta Depth d Grout Seal _ Type of Grout—_ 5 <br /> I I I"'adxm —Approx. Depth pI i Eastern Surface Seal Installed <br /> Hapaa Work Oc.+e (7 Type of Pump H.P.__ =z _ State Work Dae ✓ - f <br /> Wer,Aestn ,,on G Wall Oren-tar Sealing Material(lop 50'I <br /> Depth___ Filler Material(Below SO') <br /> TIFF OF SEPTIC WORK NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I INo septic system Permitted it parbl,c sewer Is O <br /> a,nilable within 200 feet) <br /> lnst0adon will serve: Rosidence_ Commercial_ Other <br /> h umber of Wing units: Number of bedrooms <br /> C`asacte-of soil to a depth of 3 feat: Water facie dwth--__ <br /> SCPTIC TANK G Type/Mfg _ CapacityNo. Canpartnamn _ Y <br /> PK G.TREATMENT PLT-❑ Method of Disposal <br /> Distance to nearest: Well Foundation - Property Line <br /> LEACHING LINE ❑ No.6 Length of Wtes Total length/she— <br /> FILTER BED ❑ Distance to nerum: Well Foundation Property Lite <br /> Sc PHS I 1 Depth __.—Size_ Number <br /> SUMUM.I's'S Ll Distance to ree;,,est We' Foundation Property.Line <br /> DISPOSAL PJ'*'CS ❑ __ q <br /> I hetahy ceiih, !I,2t 1 have pepue7 this appfice6on and that the work t ill be done in accordance with San Josquin county ordinances, state lows,and <br /> rues and rsio i&,ons of the San Jouluin Local Health DOtuct. <br /> Horne owrc ca licensed agent's signature cer ifioa Ile following:"I certify that In the pedwmancb of the wale for whlch this permit is eased,1 Mea not <br /> arnplcy any parson in such mean,as to tecorre subject to workman's compensation boas of Ca:tfornia.-'Cortno 's hiring or euAcontracring sipnaMf <br /> certifies de fcf aw'.�0:"I rar-,ify that in-jus performance of the work for which this permit is issueC,f ar*0 MOW persona subject to worknan's conpenea. <br /> tion kwp of Celilan.ia.' <br /> Toe&,Vlicony4qust call f I requirad intpecpons.Complete drnw'mg on let"side. 199 <br /> Signed i_. V P.Ca: �/,f Date: �O` <br /> �/ FOR DEPRNTMEN USE ONLY <br /> 2 I/ jys{ <br /> AppliuP.,n Accepted by %r 1 1�t_ Data O o V Area _ <br /> Pk or Grout inspection bs' Cat Final Inspection by Dap <br /> Additional Comments: <br /> ❑Stk1668781 ❑ Lodi 3893621 ❑Manteca 1123-7104 ❑Tracy 836d3B6 .- <br /> AppRnJrtt-Rad'm all copies to:Environments]Health Penrod/Sen cw 1601 E.Halelton Ave.,P.O. Boar 2008, Stk.,CA 86201 <br /> s INFO AMp1Hi DUF AMOUNT REK'TTED CASH NECEIVEO BY DATE IERMrY alp. <br /> ..ER tax Inv.van ,� (� L4a <br /> IN Isla < r-� ..,t.. yr7 gg-Z7 b•1 <br /> 'c <br />