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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6761 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ZW,)6 ,0 lComplete in Triplicate! _ r--� <br /> Atrplicatiat is hooby panda to the flan Joaquin Local Health District for a Parma to construct and/o4 insula the work herein dusr.rrbad. This appbcatrnn is <br /> made in coir obbi ece with San Joaquin County Ordinanc#No.flail for sawage a No.18112 for wall/pump and the Hulas and Hequlalrnns of the Sen Joaquin <br /> Local Heahh Di"n". <br /> .lob Addtma Lot PM <br /> ContractorAddress Me 4 License ND/?? !'hone <br /> TYPE CF W 1 MP: NEW WELL 0 WELL REPLACEMENT f, DESTRUCTION r I ' <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLO. PROP. LINE f� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL __ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 kuko W IC3 p�Dottom 0 MantwA Dia.of Wall Excavation Do. of Wall Casing —111 <br /> ❑ DonraiclPrhrato 0 Cxaysl Pack 0 Tracy Type ofT— <br /> Caning Specifications <br /> 1'1 Pubk n Otfw n Delta Depth of Grout Saa1 Typs of Grout <br /> I I Nrigapen —,ApptOa, OWh l I Es"" Surface Sad Installed by _ <br /> Rapair Work Dona IJ Type of Pump H.P. Stale Work Done -- <br /> Wel1 t]ast1ruc ion 0 Wer Diarrletat BeelYp Materw(top 60'1 <br /> Depth Firer Malarial(Below MY1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ir REPAI DDITION I I DESTRUCTION I ilia Septic system permitted it pubbe server is <br /> avadable within 200 fleet.( <br /> Inotaeation will saw": Residanoo__. �,onwn�rciah� Off. <br /> Nunrtter of*-1,V unim Number of bo*oorm <br /> Ctrara W OF a"so a depth of 3 test: - Water table depth <br /> SEPTIC TAP q; 0 Typo/M(g opacity No. Compartments f <br /> PKG. TREATMENT PLT.0 Method sgc1sal - <br /> Distance to rtearast: Wig Foundation _ Property Line <br /> LEACHING LINE C'1 No.8 Leapt' of km� --^ Total lengthlsize�� -- <br /> FILER BED 0 Distance to nserew Well Foundation _ Property Line <br /> eGEPITS I IOaptlr� Sim NumberlDiettancewrtaaraef: WallFoundation Property Line <br /> PONDS 0 — — <br /> 1 hereby W*that I have pgparsd[Isla ap91icsti4n and that the v&will to done in accordance wish San Joaquin county adrnances, stele laws,alki <br /> ruin end rewA44",of the San Joaquin Local HMkh DWWC! <br /> , <br /> Home oww or4ctnnd avows wwwft"cw0fiae on forowirq:"1 oarlify that in the parlonnar"of the work for which this lwrnxt as raaued, 1 shale not <br /> errrploy M1y paaon h euctt rtrfarlrtSr M W bacanr MY>istt b work+rnen'm cortrpentiation Laws of California."Contractor's hiring car sub-contracting wartature <br /> cortifies the followitg:"t cattily that in the performance oil the work for which this parrnit is Issued,1 mull employ parsons subject to work man's compart". <br /> tion laws of California." <br /> The appb— to f ! ad kwpectiom. rnplsta dravrinp on ase side. J <br /> Sigrna4 X—��— Titin:_ Date: L� <br /> R DEPARTMENT USE ONLY � r <br /> tion Accepted <br /> Apptiu clap by _ Date Arora .�• <br /> Pit or 3rout Inspection by Date F' I inspection bInspection * --flats 1 ! <br /> AddipornN Conwrenta: �V � , 1 <br /> 0 Stk 4664PO1 0 Lodi 3M3621 0 Manteca 923.71 0 Tracy W&&M <br /> Applicant-Return all copies to: Erwironimntal Heatth,Perrait/Seervicas 1601 E. Hazishon Ave., P.O. Box 20D9, Stk., CA 95201 <br /> 7 1FO <br /> FEE I AMOLWT DUE AMOUNT REMITTED CASH CK d RECEIVED BY DATE PERMIT NO. <br /> s L"M24 raEV.rixar <br /> EH 1*26 J ��✓v � j�' w <br />