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1 <br /> t 1 <br /> :p 1 <br /> APPLICATION FOR PERMi f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1801 E. HAZELTON AVE., STOCK TON, CA <br /> Telephone (208) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE 16;;UEi; '-, <br /> (Complete in Triplicate) <br /> Appke Mt M hwaft mads to tha Sr.Joequht Loci Health District for a.psmW to consouct andie in•t,:,ttMr work hereat deer abed.Tltia• r a <br /> "Wft b etOfMNMtoO welt Sen J04464n Count Ordinance No.W fa wweigs or No. 102 fur weY!WA0 mod tN IIWM Mid ReptllSOM Of the <br /> Load IMdIN Obilrlat, <br /> a . <br /> s.= Jab AOdnr .... •9 Clty. .. _... ...Lot No_ "A <br /> ` Ot+etoYs Nath t' u ILL.ID��`1 Ada«ae 1.x.,21a_..__—lea_ eA 4= Peon. <br /> Cantr Addteas. c_—�� J �.� ..,c.nssNo.—.Phone _ <br /> t NEW WALL m WiLL REPUZEMENT n CUTRUCTION <br /> PUMP INSTALLATION D SYSTEM AFFAIR C OTHER O <br /> WSTANtx TO NlAREYT., UFMC TANK , _ _. BE'WER LINES __ DISPOSAL. FLD. PROP. UNE _.._ <br /> POUNDATIM _ AGRICULTURE WELL — OTHER WELL —_ PITS/SUMPS <br /> WTOWED USE TYPE Of WALL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1 Q o dueow ®Open eon" C]101111111,11111111 OM.of Woo"cavattun______ _..-._,, Die of Well Ceiling � <br /> 0 ooe ewe/o Wm C]Glttwi Pft* C7 Treoy T!Vs of Ceeat4_. _ �- Spsciticatwna <br /> r Q FWAft Q Dow 0 0" Depth of Grout Seal YYpe ut Grout, <br /> M kdoodan .._AOOroa Depth 0 EM+ant Surfsm Seal InstoWd by <br /> Repair Via k Dana C Typo of Purrw ........___._ H.P. _ r _ �....__ .•�. State Work Done --.----•— <br /> we Oeawmewt O Wel ownew Ssalhtg Mat"(leo W1 ,..� <br /> Depth Fabler Material 1W N b VI __._.-_...._ .. <br /> TYPE OF SWWWOW EW INSTALLATION V REPAIR/ADDITION n DESTRUCTION INu wput: evrtsm risnrtrtwd If public fewer is <br /> avoitooW within 200 teat.) <br /> j9I Itlesaftwo va evow RMIdM10e CQ itIRM01al _. DIftIN _ <br /> Nuwam of I1tIMtp L,Ao* NLmber of be froorm. <br /> ChMrtRar of MA to a dw4h of 9 fee. Widal table depth <br /> SEPTIC TANK. Q Type/Mfg CiwacitY-__._....__...._ No Curnp+ l..ants .G <br /> PKG. TREAT&MW PLT.Q Maul' i Dlatx ad .- ---- <br /> DieeMtoe to twia t; Wy__ _. FcuridaWn_..___. ___ PiLopeny Litw <br /> LEACItiaNti UNE 0 No.8 Larvath o!Nraa ...,_._______ ___ Total w,put/size <br /> FILTER BED D Dfatanee to twerwt: WeINFoundation_._ P,operty Low------ <br /> SEEPAGE PIT'S D Depth —Size <br /> SUMPS D Dimance to neimsm: Well FoundationPiopenY Line--_---- <br /> DISPOSAL PONDS C_l <br /> �i <br /> I Mneby oertHy that I hew prepared this appilimam and that the work will be Anew in accu•dence with San Joaquin county o(drwnces,stats laws,ert l <br /> raise and mVulabonf of the San Joaquin Local Health Datri:t. <br /> Ho"~w or IICMteed agenCs signature OWWA the folowxty: "I ceruty that it)i1v pnrftxinarw4 o!the work for vA ich this petmit K".Ad,I libel no.l <br /> empboV any perem in such iTMnnst as to become Mlbtact to workman's IXNnparvnL,;.Lowe of(Alilorrua."Contractors hiring or eub-conuacbng sl6letuiry <br /> certW�s d w fokro tg:"I ramify that in the pedomttrt(e of the work for wNch ttua-3m nvt a Iv.,,od,I shell employ paisoM&object to wwrwrian's Cornponsa <br /> tion isvta of CAIIIIO da." <br /> The app4oartt must GPA for Ud rOQUkrW Inspections. Compfsre ot"tWrr•)or revalad at,-1e. <br /> SiVNed X.. ��1.-�� ` 3"_�__e _ _ Title: Date: _ <br /> FOR DLVi R'1MENT USE ONLY <br /> AppBcetlon Ac t;vpted by ___,i +'�.—L��ac►�_---- _ ___ Dathf�—�j�-t� <br /> Ph or Gat at Inspection by _ Onte_ Final Iitspecrvn W Date�_—F� --` <br /> Additional Com rr.ts: - <br /> CJ Stk 48"7bi C Lodl 385.3621 ❑ Manteca t12171t00C i Tracy sa:-4 A <br /> A OICArtt- Retum all copies to: €nvirunmontal Health Permit/Satvkse 1661 E. Hazelton Ave., P.O. Boz 2006, Stk.. CA 96201 t / <br /> I FEEMOUNT <br /> DUE AMOUNT REMtTTEV pal RECEIVED BY DATTEE yam. PEriMIT NO. <br /> IEEE �? c4 <br /> ♦aIISIsiNV. ,se• g�0i 0�P- Cyr S�17 trw:i� <br /> 1: •etc taall .�—_..�._.._-. .... <br /> 1 <br />