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<br /> APPLICATION FOR PERMIT
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> 1601 E. HAZELTON AVE., STOCKTON, CA
<br /> Telephone (209) 466-6781
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> (Complete in Triplicate)
<br /> Application,s lamby made in the Sen Joaquin Loral Heain Oistriet tot a permd to construct and/or InumN the work herq'n described.This applieJtion a
<br /> made,n rompbanre vfin San Joaquin Cc vity Ordmance,No.Site Int sewage or No. teff;for weN/pump and the Rules and Regular!"of the San Joaquin
<br /> Laval Health District
<br /> �(rj:'c_ //.•:,N,<._ /c%l j:%9�' c'C'C-X BSc'
<br /> Jut+Add,rss City.___—_L.____ Loi Size PM
<br /> ✓h•« //r Address
<br /> f
<br /> PWnet's Name _ __ ____ _ - -
<br /> /i't �• /iC['i!%i )'f f' �-.a•?ter�X i'/Ii' f y'r ?4 Phone /lt •"✓l'
<br /> n�4ln.•,• a _icense No. ___—__
<br /> TYPE OF WE,LLiPUMP: NEN WELL i WELL REPLACEMENT 11 DESTRUCTION C'
<br /> PUMP INSTALLATION SYSTEM REPAIR II OTHER fl
<br /> DISTANCE TO NLARF ST SEPTIC TANK SEWER LINES -----___ DISPOSAL FLO..__ PROP. LINE
<br /> FOIV:OATION AGRICULTURE WELL __—_OTHER WELL____ ______ PITS_
<br /> /SUMPS
<br /> INTENDED USE TYPE OF WFLI - PROf!t.EM AREACONSTRUCTION SPECIFICATIONS_
<br /> Indrsv,al Open Bottom Manteca D Escayatlon._. —__ Dia.N Wag Calling
<br /> Doe.eshc Pnvou• :rPaM Park Tracy Type,of Casing Specifications
<br /> Public Otho Delta Depth of Grout Seal —�-, Type of Grout—___
<br /> Irnpahon _ _ Approe. Depth Eastern Surface Seal Installer'by--------
<br /> Repair
<br /> y____ --Repair Work Done Type of Pump _ H P .. __- — _____ State Work Done
<br /> Well Destruction Well D, liter $ennng Malgnnl Itrq 501 .___ ___. . __.___ ----—_--- C
<br /> Depth Fele, M.nerial(Below 50'I
<br /> TYPE OF SEPTIC WORT. NFW INSTALLA:ION RFPAIRIADD1110N . DESTRUCTION I (No septi:system permitted i'public sewn m F,
<br /> avaeable within 200 leas)
<br /> Installalron wd sem!•' Residence Commercial Otho,
<br /> Number of kvmg mats. _ _ ._ Number n1 bedrooms
<br /> Character of soil tri a depth of 3 feet _ _ - __. _. _.__ ____.._.. _.. _ .. Water (able depth
<br /> SEPTIC TANK - 1vpf.rMfg Capacity__ No. Compartments _—__—_ _ !(S/•�
<br /> PKG TREATMENT PIT Method r'Disposal
<br /> Distanca to nncresh Well Foundation __. Pn�penv Line
<br /> I'ACHING UNE /' No R Irnq!i,M tines r ��, '`T. _ _ TT fill lengthisive /.Yi- ���-� In
<br /> /
<br /> FILTER RED Del+.ern m ne,ua• Well i .� Foundation Z}' Property Line —__—_.
<br /> SEEPAGE PITS Depth Site ./,o Found
<br /> F _ mbar
<br /> $UMP$ Dwance To nenn•-.1 Wnll v.. t�! oundatlon P•op nv Line
<br /> DISPOSAL PONDS
<br /> t Enretry cerlily that I have proper"this applvahon and that the work will be done in..-rordance ssr th Sen Joaquin county otdmances, stale law,, and
<br /> nAes and ,equlaticns of the San Joaquin Loral Hnnllh District
<br /> Home owner of brensed agent's s,gnar,ure r,ember m,e following "1 certify that in the performanrn of thir work for which this MILT n Issued, 1 M dI not
<br /> e,nviov any person,n sad manna,as In harame sublect to wa,kmnn3 compansation]am of California."Contractors hiring or subcontracting signature
<br /> candles the 1ollosv,ng. 'I eerily that in the Pertnrman"M the with for whish this Permit is issued.I shag employ persons subject to wnrkmen's com lana
<br /> I,Un laws of C.ed,.eea'
<br /> Th. mch-ant mu-f required,Wrpvn.,n; fnn.pinM d•awou an,evgrsq side.
<br /> Data •t .'•Y�'-'
<br /> FOR DEPARTMENT USE ONLY
<br /> Dare ; - � ) _f Area
<br /> Aoplrt-coon 4rdented by /fes - � " I - _- __ _.
<br /> . .., f•,cul Ir•.[.•conn by Da•_ Final Inepection by%/'� w_ Data
<br /> Aq.l.••,nal G,^,mints - .. - -
<br /> ',o, MA'6W l,rb 359 352, M,mrn,_, 823 N Is T'tacy 1056.-8,.
<br /> Appira•,I Re:,." ...-e.r.r nil', iln r,•h Pmrrn `err res Iwo F Ilatgltnn Ave, PO Be. 2009. ilk., CA 95281
<br /> ,(( aMp.,.•' �ee i ry,u., NNm••lO _r'
<br /> �H 1 RrLt VtD Ov I DATF PfNMn n'el
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