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<br /> APPLICATION FOR PERMIT
<br /> I SAN JOAQUIN LOCAL, HEALTH DISTRICTA
<br /> 1601 E,:HA7.ELTON.AVE., STOCKTON, CA n
<br /> Telephone 1209) 466.6781 ,a
<br /> PERMIT EMPIRES 1-YEAR FROM DATE ISSUED
<br /> (Complete in Triplicate)
<br /> Application is hereby made tr the Ban Jo UdnAr
<br /> :'`k
<br /> made In Local Haahfi District lora permit to construct andbr Install tho work heroin described.This■ `f`-
<br /> complleme with*•t+,,,requln County orAinawA No,r>Ae for new ppllcatlon is i i
<br /> Local M"lh Dlatriel. +tea a No. 1882 for walllpump and Iho Huiub and f ouulatianS of the San J 4, `
<br /> Job Address yS3— �T/t rs a T
<br /> Ci1y .rir1 CJ� Lot Sse---- � PMr,aE
<br /> ` Owner s Nam S", r ! .R Address 3 a 4P*4VF#9ft ow-f a c-
<br /> x YOCF•t�E �y _ �._� Phone
<br /> {
<br /> Contractor 'Addreu + � i/f�1J r tArG i�� Cu./�/ -
<br /> License No,ly' '? ._Phonel'�i f7r. k
<br /> TYPE OF WEItlPUMP: NEW WELL JWWELL REPLACEMENT ❑ DESTHUCTIUN I.I '
<br /> - PUMP INSTALLATION Q s„ , r' SYSTEM REPAIR © OTHER L) TY�
<br /> DISTANCE TO NEAREST:,SEPTIC TANK.,,.. ,€, SEWER LINES : DISPOSAL FLO. Sir ;
<br /> FOUNDATION PROP. LINE
<br /> —,.�"^` AGRICULTURE WELL ^ OTHER WELL PITS/SUMPS iL
<br /> INTENDED USE _TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> ❑ IndustrialK, lz- -- N rt�t N m W
<br /> ❑Open 8otttxn �f+* Q Manteca Dis.of Walk Excavation
<br /> '�Domgtk/Privau ,IE4�Gravel Pack Tracy vG Dia,of Well Casing ,
<br /> I_ Publk ' ;�' r Type of Cosi Specifications ,�/ �Y
<br /> Cl DMta Depth of Grout Swf ��
<br /> I ! hriRation a• S Surface Type o}Graut �Y�`N� k: +
<br /> Depth
<br /> Dgptlt .1 1 Eastern, „; ace Sea;Installed
<br /> Repair Work DanaO YPa of Pump - - -
<br /> T
<br /> .:
<br /> '
<br /> Well Destructioni HP State Work Done y�Dia ertii
<br /> SeaNnp Material(top S&I
<br /> Oopth
<br /> r� Fkger MataW(Below 601
<br /> T yPk OF SEPTIC WORK: NEW INSTALLATION 11: REPAIR/ DDITION i l DESTRUCTION l lNo wptic sybte,n permitted its
<br /> public wwer is, ~s
<br /> ior
<br /> Installation vA serve Rstlidartoa^, *� available within 200}eat,I
<br /> Number Of kvirtp Unita:' Numbs of bedroomy t� �
<br /> Cfwacter of soli to a depth of 3 lies,
<br /> SEPTIC TANKWater table depth
<br /> ❑ .Typo/Mfq Capacity No. Conip ;
<br /> PKG.TREATMENT PLT,p mpartmant�
<br /> f
<br /> + Method of Disposal X
<br /> Dipanm to nssrast. `Wag
<br /> F
<br /> tttxtdstilut
<br /> • _ _ r. -Lina
<br /> I h 1
<br /> LEACHING UNE D NO.A L6nith of Gitss'' °. ':
<br /> FILTER BEDDistatta Total krngthlsize
<br /> C1 to rtsarest: WeD FoundationPro pd y Li
<br /> �. n Line
<br /> SEEPAGE PITS k I . p
<br /> SUMPS L1 Number '
<br /> L7 Distance to nearer: Wall :Foundation
<br /> DISPOSAL PONDS ❑ Property Line
<br /> r ..
<br /> I hereby certify that 1 have prepared this appNcetlprt slid that the work will be done in accords"with San Joaquin county ordinances.State lava,end-. lr,
<br /> ruins and re1ltrlatiors of the San.loaqukr Local Health 0$trict.
<br /> Horne owner Or 11canaed aQa11'a aiBliitipa certifiaa the f
<br /> empSolr any Paton lit such manna as v CanlIte •..I ca*that In the Performance of the work for which this permit ks issued,1 shep:not
<br /> conifies the f to workman's sation�Irrs�CaGfOrnia."Contractors hiring or sub conuacting signature �
<br /> ',.I«�Y dist in the Pwtcm Snw Of the work for which this permit is issued,1 Shall employ persons subject to vrorkman s
<br /> tion laws o1 California." composes
<br /> .r
<br /> The appficant cc"for an r COmplet on reverse Side,
<br /> Signed rGnawv. t l
<br /> Title: Dal.:
<br /> FOR DEPARTMENT USE OIC Y :,,`
<br /> a Application ACceptad by -
<br /> - Osis Area C/
<br /> Pir o/ �I '
<br /> �suaet nspaction by Dale Final inspection Date
<br /> AdGitional COmmanta:
<br /> { C] Stk X888781 Q 1" US-3621 0 Manteca M7104 +.
<br /> Applicant-Return ail copies to: Environrrremsl Health Permit/M71040 Tracy �i6 k3386 - '
<br /> Semicas 18D1 E.Hazelton Ave., P.O. Box 2009. Stk., CA 9=11
<br /> FEE DUE AMOUNT REMITTED
<br /> I.
<br /> INFO AMOUNT CA RECEIVEO 1111 Ill' DATE
<br /> PERMIT-NO,
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<br /> • rM Il21(REV.rrw4, �j
<br /> EN.2c fr - /1
<br /> -71
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<br /> ..-..wr+r .,., +�.3`,a,..�%;....x�s1,i;.41:'�r had��,� p'it.,4.n-. z ii '• � -41-1115-W
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