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T
<br /> APPLICATION FOR I"""1T
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT l l
<br /> tfint E. HAZELTION AVE., STOCKTON. t'
<br /> 16ephone (2091466-6781 N,
<br /> PERMIT EXPIRES 1 YEAR FRO_M_DATE ISSUED
<br /> f
<br /> (Complete jr%j6pllcatel TNS acrtIfat'nn
<br /> rine(t0 construct and+or install ihP wrnk ,,,inn Ae(Atm i n1 the San Joan'+'"
<br /> I Health D'Stnct IM a M' iP tot well+Dump and the pules and Hep ` e
<br /> Application is M•'ehr
<br /> 1.•„de 10 the San Joaquin lora n, ¢.691au yw•N7N or No
<br /> made In c"mpl'ance w.h San JUag41n CMe+ry Drdman(p n
<br /> lural health D'slntt. - M -
<br /> (! tc r'. P y
<br /> C,,r51:41 f1t�,�� L _.�-.r-�---
<br /> Joh Add,Pis Jt;_'.'<.:,-f_!t-f(✓'' _ .._ ....-_._..._. ` ./��` c' _ fMInM- _2.`'..] .dC..'.
<br /> 1. !• 'I c �,dq'ns~'Ci 5'G. G.•
<br /> A r- f d�►r- Ph,
<br /> Uwnet s Nam" _...r fM ;
<br /> _.Lltenae No. _
<br /> I.
<br /> Contractor �SG[� �1/�/-t+^ - UF`tINUCTIO4 K I
<br /> NfV�WELL WELL REPLACEMENT OTHER n 1 6
<br /> TYPE OF WELLIPUMP TI L SYSTEM REPAIR Ll PROP, LINE
<br /> PUMP INSTALLA O DISPOSAL FLO_
<br /> SEWER LINES ------ PITSISUMPS L�'t
<br /> DISTANCE TO NEAREST: SEPTIC TANK .�.� T IA I'_, OTHER WELL -- -- -
<br /> AGRICULTURE WELL _ _ -
<br /> - FOUNDATIONManteca -
<br /> STPUCTION SPECIFIC of WNN Cav”
<br /> ATI �IS_ 0'a EI
<br /> . TYPE OF WFII (a a- L
<br /> INTENDED USE T O, E(15elfe titans _.rte �t
<br /> - t�((7pen RMp+f^ PR(TRl E M AREA CON
<br /> [;Industrial }pIffc Smut C P-Me
<br /> Me
<br /> ,' Othee :u11.ai a SPaI Inil�l et1� Trm
<br /> . I �
<br /> Public
<br /> I
<br /> ,'6) APMn. (tutu, Eantr,n $IAb`Vnr►DJWN
<br /> I"ISIAl.ur+ - L'
<br /> - 1(P r
<br /> Repan Work of PumP W
<br /> k Done SPal,np hlatmlal IIO(t yp'1
<br /> Well Destructan ?� Well D'ametc, J Filler hlater'al(Below 50'1 _ permitted a,N'nlc sower is cJ�
<br /> Depth _J INn sPPlrt srslertl M•
<br /> HI PAIR ADDITION 1 17ES1RtICTION lest.(
<br /> available vrlthwl 200 �
<br /> TYPl OF SEPTIC W(TRK NEW INSTAtIATIt)N' `
<br /> Installation will serve Residence - Commercial (((lite. _ Water table depth
<br /> Number Numbel Of bedrooms _ ---
<br /> -.._-..
<br /> N
<br /> ber nl Irvmp un'Is _-' No. Canpart"'entf -
<br /> Cha,,Icte,o1 toil to a r4•pth of 3(PPI - Capacity._ -_- Method of Disposal
<br /> SEPTIC TANK Tyrw!Mfp
<br /> .1
<br /> P,capPrty(iris --- ----- ---
<br /> PKG TREATMENT P4 T I I Foundation....-----^'-" -
<br /> Dlstante to,learrst Wen _.. -_--..._.!•--—
<br /> Total lenpth7e411`e. __
<br /> IEACHINce l INE --
<br /> I 1 NO b l Pnplh Of MRIs _ plop"line -
<br /> W(41
<br /> (1 111 MA,PLt ----
<br /> FILTER BED D,stanve . .._._-___..-.._
<br /> property(M)e _.------- :)y
<br /> SEEPAGE PITS wpm cnu,nannn
<br /> SUMPS l I Umtanu+t0 Ilearest nc�,state laws,and �
<br /> I I n eccor4atxe with San Joaquin county Of
<br /> dna d
<br /> DISPOSAL PONDS amt i%.stood.I shall not
<br /> Certify that I have p,epa,pd this APpIN&at1.a end that the work win 1 r Ik'fw' which this pe
<br /> 1"'Shy an V u"Local I/ealth Dllulct „,r,Mmsnte 01 IM wok for wl1 tfsclmp sipnatute
<br /> rubs and,eputahals of the Son JnAgl 1,410 l„np .y cert'la that In the( lima"'/co"+penu
<br /> H,,W owns,of licensed epeM's signature ctw%*s the i,msn's t.umponsalW laws of CNdprva"Conurctnsubject tows
<br /> sun Mµeh mannel As to tMttNlMl Wnce 10 rrUr imil 1`.stMdI NNN M�pk71 persons
<br /> eft+f7loY any p� rlamanu o1 tis work f x which this IW
<br /> IM"
<br /> es the tok-09-"1 certdy that m the pe
<br /> tion laws of California." >febl d,ow,ny on few*,**s"��rr�, Date'.
<br /> iemI mu t Call for ON r lured Imtlechons Cnmt The app(
<br /> �_ FOR DEPARTMENT USE ONLY
<br /> Date. [�1--
<br /> \ k \ I�1 Dale y
<br /> Appl'uh'n AtcPpted hV --}�" � _.-----...t(itis� \
<br /> Date �' S`� Final Inspe _
<br /> �, t z .►lit?
<br /> Pd or Ofpnol Inspectan by
<br /> +� 635 M
<br /> �`� '''t` _ 7101 Afacy. "liStk..CA 952(11 ..ti. �.
<br /> Additional Com"aenu: Menteea0 ..,{issI E. "lion Ave..P. 8ov ZOCl3,
<br /> t 1 Stk abs 6761 n Lodi 369.3621 Cj��� c ll' ' � - S-S -77
<br /> Applicant Return all copies to: Environm'rn1•1 Health Permitl5 1 C ;� 'J
<br /> � DATE PERMIT NO
<br /> �� RECEIVED BY _
<br /> --�--� AMOUNT REMITTED CASII 2 L
<br /> if[ AMOUNT DUE
<br /> INFO
<br /> V
<br /> tN 1,70
<br />
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