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y. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> a .Sit ' i�► ��. T r <br /> (Complete in Triplicate) ; <br /> Application is hereby made to the San Joaquiri-Local Health District for a permit to construct and/or install thtW hti i k".4hislapp cat! n is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rulesand.Regulations of the San Joaquin <br /> Local Health District. v <br /> Jpb Addressa <br /> 'Wr or <br /> City Lot Size <br /> Owner's Name "Address Phone ' <br /> - <br /> Contractor cd6kq Address License No. Phone <br /> TYPE OF WELL,/PUMP: NEW WELL ❑ WELL REPLAeE, FNT ❑ DESTRUCTION ❑ , <br /> .. _ !! , <br /> PU INSTALLATION [1. SYSTEMAEPAIR „OTHERO <br /> DISTANCE TO NEAREST: SEPTI TANK SEWER LINES <br /> DISPOSAL FLD. � if�,:LINE <br /> r FOUNDA N AGRICULTURE OTHER MCL�� PITS/SUMPS <br /> 3 <br /> INTENDED USE TYPE OF W PROBLEM AREA ONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom :.� Mante Dia. of.Wed Excavation Dia. of Well Casing <br /> ❑ Domestic/Private © Gravel Pack Y Type"of Casrn "'a` �'' s `s" <br /> + g Specifications <br /> i <br /> 1'1 Public F1 Other Delta Depth of Grout Seal Y"`,-Type of Grout y <br /> 1 i Irrigation _-Approx. th., i I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of mp H.P. State Waw Done { - <br /> Well Destruction ❑ iarneter Sealing Material 1 p 50'1 + f <br /> "pth Filler Material,{Below 50'1 <br /> TY—RE OF SEPTIC WORK) NEW INSTALLATION i i REPAIR/ADDITION I I DESTRUCTION , Nage tic system permitted it public newer is <br /> fives b within 200 feet.) . <br /> installation will serve: Residence� Commercial— Other i.. <br /> Number of living units: Number of bedrooms t ..✓ <br /> Character of sal tc adept of'3 feet: iter table depth <br /> SEPTIC TANK ❑ TypelMfg Capaci `� No..Compartments <br /> PKG. TREATMENT PLT.D �,< 'Method of Disposal <br /> Distance to nearest: Wel Foundation _ Property <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ' <br />" FILTER BED ~- <br /> r ❑ Distance to nearest- Well Foundation Property ire i <br /> SEEPAGE PITS 11 Depth Size <br /> Number = 3� <br /> SUMPS 0 Oistance to nearest: Well Foundation Property Lined <br /> DISPOSAL PONDS C1`` c �'1.;': -s <br /> I hereby certify that I have 1$repyared this application and that the work will be done in accordance with San J uin roynty ordinances, srtate taws, and <br /> rules and regulations of the$an Joaquin Local Health Di§trict. a : :. J' <br /> Home owner or licensed agant's signature certifies the following: "1 certify that in the performance of the work r which-this permit is issised. I shall not 4+ <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contr4ctor's hiring or sub-contraptirig signature P <br /> certifies the following: "I cel'tify that in the performance of the woik for which this permit is issued,I shag em <br /> tion laws of California." ploytpersort$subject to workman's compensa- <br /> The applicant must call for all required r spections. Complete drawing an reverse side. <br /> Signed Titre: a �;r; <br /> Date: <br /> FOR DEPARTMENT USE ONLY S , <br /> Application Aeceptod by ? <br /> DateJ Area <br /> Pit or Grout Inspection Date Final Inspection to <br /> Additional Comments: <br /> a w TtdoO Stk ,& 681 71Q4 y <br /> L;:a <br /> s Applicant Relum alt txO06to EnvUanmrmta)Fteahh�errnttlS 4601E eY Ave <br /> i 1...X r �`{�{� V:AT, .., w • <br /> fi­FEE <br /> �eY1I�ILV '7 .1� y� ` <br /> z -. - ��&.6� }�NFt�' ��.�'•+^" w 6 %fie. - g. f��+ .arti'�. �.,- ti ��RI�IY: ; ''�' '"�'; <br /> kr r*�E'H 1121' RfV t7e137 ��s4 �*`° � •� x 3'. tt ', vee�g'ASE � >i " .. �:..';rh " �£,:�.• f°'P ' <br />� '4'� � £+.•, - - �^ ° `, `"��,� #"•- r - r� �r'`'�rt�.,� '�•,x"'.q,��' ° rr-!'�, -fr eA7`.+agr. y 1. � �. <br /> .y .:�, ,.,�-�r p.;- y�-''�=a"'""""�s.�•j.•-. .,,5•y..,•c .;� �.��s�, .�,.�r �s'fi""' i ^'��crM.. �•... ��.p �-.;`� �q� '�• s 7 <br /> n�_ y -..tX....r°r. A�•:�-.�;. d,,{. '�a�".�`,-°''il�,��3w'1a£,s...a;�.-.. �r.>B�:<:�:�'.r..°•,rx-,. <br />