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<br /> APPLiCATION rOR P4 iMIT
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> Tl'�t E HAZELTON AVC.. STOCKTON, CA
<br /> Telophond 1209) 466.6781
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> 1Colnpjoje in Triplicate)
<br /> ic&Wn is ,.r
<br /> i install the work
<br /> Application•s hereby made to the Sen Joanpn+Urd,nalneelNo, 549foraawege w No 1 xW#of wall,pumo and the Rues end)Rego al tions of tM San JoY4uln
<br /> node in Compl,enca with San Joaquin Co rV ?,
<br /> L•,;pl Health District (Os-J ,/
<br /> IWX S119
<br /> 'nh Aridrrss
<br /> Phone -- !
<br /> Owner A Name
<br /> IPhoneiGr-� 1
<br /> Contractor's Nai a� .__.___~ -ELL RUCTION 1.
<br /> NFW WELI WEPLACEMENT
<br /> TYPE OF WELLrPUMP' SYSTEM AFFAIR OTHER
<br /> PUMP INS TAI LAT ION / DISPOSAL FID..__... PROP. LINE _C--
<br /> i
<br /> t),SIANf_E TO NFARF.ST: SEPTIC I C TANK lej SEWFA I INES PITSISUMPS
<br /> AGRICULTURE WELL OT+1ER WELL
<br /> _- _--
<br /> FOUNOAT ION
<br /> _
<br /> INTENDED USE TYPE OF WEI PROBLFM AREA CONSTRUCTION SPECIFICATIONS
<br /> LDIR.of Well Casing _---
<br /> tr,dustr,al Ogen Batten, Mentaee Ole of Well Excavation .- - _. Specifh.�tfona
<br /> 1refy TVDa of Casing
<br /> Gon,erbc Private Glave)Pack Depth o1 Gmut Saal Type of Grout . . -.-.--•---
<br /> Other Dolts
<br /> PublicH P litigationApprox Deoth Eastern Surface$$Of Ir:atelled by
<br /> Work Ilona
<br /> 15�
<br /> Reptur Work Denof Pum)
<br /> Della Type f
<br /> Well Daelfl/Clip/1 Well Diameter Sealing Material 'top 5(I I
<br /> Filler Material(Below 50'1
<br /> Depth (No Relive ayrtem ixlrmit,ed d public sewer,e
<br /> TYPE OF SEPTIC WORK NEW INSTAL I-AT")N I FPAIR'ADDITION JESTRUCTI N evaIIRNe within 2W feet.)
<br /> Inslallavon w,11 servP Res'""cR Corrnnrrcial Other �.
<br /> -�5
<br /> Number , h ng units Number of bedrooms
<br /> Water table depth
<br /> Character of soil to s depth of 3 fePt'MfNo. Compartments
<br /> Typeg Cepnc tV —
<br /> Scpl'R: TANK Method o1 Disposal
<br /> PKG. TREATMENT PLT d' Proper E Line
<br /> Distenre to^oareWell Foundation
<br /> -. Total lengthrnee
<br /> I E.ACHING LINE No B Lon9111 of I,naG Foundation Propeny Line
<br /> i+a
<br /> Fli TER RED Dislaore to nrelest Well
<br /> Number
<br /> Depih
<br /> Sire _ - .
<br /> SEEPAGE PITS Property Lina
<br /> fou^dation
<br /> SUMPS Dw nr in nrP,Rnr Wr'' .
<br /> 5:•!
<br /> DISPOSAL PONDS - --
<br /> Ir.r,'n in nn,l tlr' •i,^wnrx will he done in accordance with San Jnaputn county ordinances,state laws, and
<br /> .t
<br /> 1 hereby certify the' I heva p,RPnlR(1 It"s opD�
<br /> ,idea artd regulations of the Seri Jea,lino Lor,Rl llnalV, D�strnl
<br /> Home owner at licensed agent's 1,grlalwe cerrihes the follgyving 'I Cenlfy that in the l performance Of California
<br /> of the work tar which this permit is issued, 1 chs not h
<br /> i hat rn n j (x,rinrn,anC'e l the work I ' which this permh Is issued.I shell emplOV Persona subiect to workman's COrTlpenaa• :€
<br /> ampinv any person in such manner es ro I,Rcurne aubler,t to workmen s rnmpenaallon laws of Catifornie' Contractor's hiring or sub contracting signature
<br /> ,.ertilier the following "I con fy 1
<br /> lien taws of C:abforrnr. -
<br /> Tr,e BDpbcarit n call all ragU'rPr1 r,�M!,tone Goawing wing On reverse side `- •�1r
<br /> Dote' f
<br /> 5gr,Mtl 14 '
<br /> FOR DkkPARTMFNT U8E ONLY (.
<br /> l Dara ltrt Qi
<br /> Application Accaplod by �'C' •+•✓� "",`
<br /> f,nal InspectioIby j.Aa.. -1/.dt�.xlS.s?J Date - L
<br /> r`il pt Grout In9r�!C tiry,by 1x1
<br /> r 1 aR . CSC.'. 4�E-- gip,
<br /> Ad,Utionrl Common's �(.�.- •-�'- `- Tracy 8356386
<br /> Stk 41%6781 /�f�Lodi -1169 Sri?t Mantacx 82=1 11t1A If2M, Stk , CA 96201
<br /> ADDlicri,t Return all COVera to Envat;r,m9ntel Health PRrmil Serwree Y)1 E Naieltnn Ave P O Box
<br /> I
<br /> :V ECEIVEC By DATE PERMIT NO.AM(!,.NT aFMITt1D CASHNil' i
<br /> I
<br /> �x�
<br />
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