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APPLICATION. R PERMIT, . <br /> SAN JOAQUIN'LOCAL'HEALTH DISTRICT <br /> . ` x 1601 1- HAZEuTON ANE:; :STOCKTON. CA <br />? t <br /> Tetephotte (7A9) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUFM <br /> ^•- U� �� , .. 'j, k, iCOrxlDlete�inTriplirate} <br /> � uin <br /> Awlca( mads iga is here to**e Joaqf1 afth District for a permit to construct"and/or"install the work herein descnbett This appl;cation is <br /> tl irr 3rratie in ownpfiance filth' n, u III CoitrrtjrOrdiryanea ll o S49 fre sewage or No. 1862`for weUlpumq and the Rules and Regulator*`o!the San J m <br /> Local HealthC4. 0 <br /> Jvb Address r, iY53'K, <br /> City _ Lo#5rse PM <br />§ <br /> Owner's I+leme � Addt955 <br /> - hone <br /> Contactor Q c Dd IPx I& �dres 6 Com. hoo, I, <br /> License (lo.��Y l /7 <br /> 1 Phone <br /> TYPE OF WELL./PUMP: N5V—WELL'D WELL REPLACEMENT Q DESTRUCTION © <br /> PUMP INSTAL ATIOIiI O SYSTEM REPAIR 0 OTHER ®'" 01tu46r l� �2 <br /> DISTANCE TO NEAREST: SEPTIC TANX- ;_ SEWER LINES T —. _ DISPOSAL FLEA.-t-, ,��OP. LINE f <br /> FOUNDATI0N AGRICULTURE WELL __��„„_ OTHER WELL �l T PITS/St1MPS T <br /> INTENDED USE TYPE PF WELL PROBLEM AREA CONSTRUCTION SPEGF,CATIaNS <br /> 7 Industrial II Open sottorn Ntl (,7,MMante�,� ca CNa.-of Wee Excavation' Dia.of Well <br /> Casing <br /> [Q_D4mastrc/Private._ C� Grarre(Pack l TraoT., hype of _ Il L Specaficatiorts <br /> Ci PublicD p Delta Depth of Grout Seal Type of Grout � M t <br /> El Irrigation n 111 LA�.De;O. Vit..Eastern Surface Seal Installed b1 <br /> w. Repair.Work Done_ 0 . Type Of.Pump/, „_ ,_,_ H.P. State Work Done <br /> Well Destruction © well Diameter _ Sealing Material Imp la`IPt <br /> Depth Filter Material (Below W) . .. .. <br /> TYPE OP.-SEPTIC_WQRK,.. NEW 14ST4LLAT10N.,Q_REPAIRlADOMO Nf p DESTRUCTION E1 (No septic system permitted it public sewer i6 <br /> available within 260 feet.) <br /> r Installation will serve: 'Residence _�- Ccmmmercial._ _ Other <br /> Number of living units:" Number ofibedraorns,__� <br /> _ Chdractsr of soa to a depth of S feet; <br /> Water table depth __ <br /> SEPTIC�'JW K," :. � No. Compait�ments 4 <br /> PKG.'TREATMENT PLT.q <br /> .. .M_ Method of Disposal <br /> bistanee tq newest: I Well,,------- Founda6w Property Line <br /> r LEACHING LINE a � _No Ll k <br /> ., Length of Ifnesf '" - Total lengthfsi_ rite . .� <br /> fILT£R 13E0 'Lbiatanoe til nearest' w •Well FowJndation T <br /> Property L' <br /> 1 $9EPAQE PITS: Q Depth Sim <br /> Number_ <br /> r SOMPS - - - <br /> E7 Istanne td neatest: Well .- _ .. . . _ . <br /> ' I � � Four►da -Property <br /> Line <br /> �ISPOSAZ~PONDS., <br /> I hereby'cWtify that I.have W*MrOdAis m Okstion endthst the work vW11 be 0"In socorrdance with San Joegclin county ordinances, state laws, and <br /> rutoa and regulatiot of the San Jotinuin'Local health District. <br /> Home owner or lwWv*d'ageWa,slpnatura• the following:41 Cer&V that h the pertormanoe d the work fpr which this permit Is issued, I shall not. <br /> employ any psrton"In such manner a6 to beknorl'ra"subjset'to Wp►f Mre11 Compensation laws of California."Contractors hirft or sulci-contracting signature <br /> pprtifiea the follow"..-.tdcertiftr the performance of the Woric'for which thts penmh Is issued,I stall employ persons subject to workman's cqmpense- <br /> tion Uwe <br /> i Tfa <br /> t p or I <br /> ,Rleterrewi <br /> t. <br /> •d <br /> reverse . <br /> i rI7d.. .._ �.. AxArTige. (J 4Y <br /> Date: <br /> 3 FOR I?lrPA1�tTMl` USE ONLY { <br /> M, <br /> Appli�atkxt Aooep1W by ` } = fff4r7 <br /> ;Date <br /> Area <br /> Or Li. ! <br /> Grout <br /> �.�nspsctlon <br /> by ��]ats ,.� Final InTeby :Date <br /> i <br /> Addis onat`Comrmenur 1 " <br /> —{ "` sl 7s1 t - todl 399362 f ""Cr�4Car i ffi3 7104 ­0 0,t <. <br /> y ppc R: Rewm a1 WON Tai. ErWlrgrKprn���redtlt /Servion y80s E. Hazelton Avi P o. /cool 2 08 9 ' <br /> - , <br /> 1 <br /> 4 {4. <br /> WFOG Vt DUE AMQUNT PEMITTEt?° EC'l A io oAv1 } fiISRAAIT TLD. 4 <br /> } w4 <br /> i <br /> : <br /> �GyraS�r# Q <br />