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APPUCATION FOR PERMIT <br /> t•' Yf e.r ti x� ••a i <br /> =ti SAM JOAQUiNtOCAL HEALTH DISTRICT <br /> ,.. 1801 F- HAMI TON AVE., STOCKTON, CA <br /> Telephone Q09)-06 87$!' <br /> +^ FROM"' ]ATEISSUED;" : rrw���� rilt+•yal~to :�x,iy <br /> PERMIT' EXPIFtWl YEAR ;• <br /> a'rl.'t ■:. ! �3`ax"n.�°f� . T, 3a r.t�;r 1 C <br /> (I orriow in_7'riglicate}t �E. ,ya, Ti f's;#Un.Fr <br /> n web �CtIy .»RS1t+4i. if 'i-, ,;: +1I •C'oi acs e•,= <br /> ' ApPIicstiar+io 1Y rrrade to the San JosPht Loeal htertltl't nhsp+tt for a perm#t to eomtruct atMtar ie+std the work Irareir►described.:Thfs application is <br /> - Ordin�e NO.50 for sewage or NO.1082 for wen/purro and the ROM anA Aagufe�na of'th a San Joaquin <br /> made#r catnPll with San Jostluir►COuntll t "i "� ` s•'`• w <br /> Wcai'Hea th-r3isttict• s r'•" ;t' +.• a i � <br /> '.� .�• Ji'` +;i��fs.p-T3 }!3'.'3 . <br /> -lie <br /> "� _ <br /> ,� 1 Q or% I.'. E -:-"Y q t-'tE '/►!�`► n'Lot Stye q tray' 1=M <br /> Job Address . - }§ �'�..r3 f' EI:k: .gra t i!'-' -.: - <br /> � E <br /> PhSne <br /> Ownar'�a Nsmai =Address- : :,_•W - --s- - - i <br /> �es]sti�,e=3 a�w Ia1R 1 +�rti�� ""'"' �....,• �9/ _......_,. <br />{ Ctractor ! dress B��e..<. oesT. .�. ense-�a� <br /> TYPE OF WELL/PUMP: - NEM!VML © WELL REPLACEMENT L't DESTRUCTION Q <br /> PUMP-INSTALLATION © SYSTfm REPAIR•13 OTHER Q i <br /> SEWER LINES DISPOSAL FLn. PROP.-LINE <br /> DISTAIVCETpNEAREST: SEPTIC-LANK _, _ } <br /> FOUNDATION f AGRICULTURE"WELL 77 OTHER WELL PITSfSUMPS <br /> f OED USE TYPE OF WELL :PROBLEM,AREA- CONSTRUCTION SPECI€tCATIONS <br /> ©� OIs.of•Web Exesve ion n#a.of lAleli Casing <br />! ❑ Industrial © Open Bol arts Speciticatlons <br /> p O�ciPrtvats ❑ Gravel Peek,;; .©:�'rraTv Type Cesirt <br /> © Pubrm ©Othef 0 Depth of Grout Seal - - Type of Grout <br /> O'IM&tkm --ApPr*x. Depth Q surface Seal Installed by r <br /> H.P. State Work none <br /> A60b,jWork Bane ❑ Type Of Pump - r 1 <br /> 1lVaa QesuucHofl ❑ Well Olarnatea. '• Sealing Material Itap•6G`l <br /> IDaMh Filler Material(Burr W). .� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAfR/A HITION ❑ DESTRIJGTI lel ta�Q pdc sY n rn 2i0 iif��mer is <br /> evaeahlo with+tn afeet.)t.).l + <br /> Ir enation VAN so".• Roodence Commercial Other <br /> Number of hang units:.,_..— Number of bedroom <br /> Character of son to a depth of,8 _Mister table depth C <br /> eS Cepsciry /�d0 No. CompoRments %L G <br /> SEPTIC TANK hype/ Meltod of nisposal <br /> .PKG.TREATMENT PLT.Q <br /> Olsta ie.to•neares Well�- F rr►datiar►-�$ Una <br /> LEACHING UNE No:& hofrrm <br /> FILTER BED C] I�tance'90 ,Well, . Foundation /0 One <br /> utYEa. <br /> I <br /> SEEPAGE PITB E3 •Depth ^ 4— Number <br /> Sl�Mf'S u jV Histones to nearest;_ �We!!._�_ Foundation' f - <br /> if <br /> DISPOSAL PONOS © state� ,and <br /> +cadnh~gY hBf th�'vvtgtc vYNCI l3»ae or`darfce with 5an�e ur @66M ordinances, <br /> I herebY a uft that I have ri��tW� ,. ii I. <br /> rules and regulations of the Son Joaquin Lord Heafth.H'MdCt. nqt <br /> Home owner or licensed agent's sigr►atu�e Certifies tris fdlo+Ning "I ca"Ify that In the'pelfomrei�e of the forwF►1cl,this permit is issued,E ahsN <br /> amPialr any person in such manner as ta`bacaml W*ct to workman's adm4e-Asa%6 ews of Clt ftn'1ia."Co- rector s hhing or sL4t cal'�tf sect+ng siQnatu�, <br /> aeraiios the foNwruitgO:"I certify tIr$t tfle of the wo*for which th�i permit is lssuea.I shall"einpl�.Persons subject to workman's pompe <br /> tion laws Of California-•• ��t*►�►� . _ � . <br /> 7fa appflcant for an required Corz�hets drawirsg oa reverse side r _ ";14 <br /> .� �6• <br /> -Hatt:; <br /> ill d <br /> "DE1+7�R wi CIA'bfl�url- <br /> 1 Application-Accepted bV' } Arm <br /> ` _ - ' Final Irspeation by <br /> •Pit # Dew-�—_-� <br /> 1 or-&Out Inspeown by + E <br /> Additional Comments <br /> ❑Stk 4664761 13 Lada SO-NIM s +C]Marvto6- 123-7104 - ©•Trwv - <br /> ' Applicant'Return aft copies to: Onimnmarria!-Health Nm*/SjMc�1�E11.t..Wazefton Ave:. P.O. Box 5009,£Stk., CA 9�1� ` <br /> " ";K w[ AMOUNT I]LI AMOUNT PEMITTED _ . -CA$F{ ; RECIV-W BY�.. DATE P>rRfNfi'NO. <br /> 4� r'kHlg�yprEy.A/®s3 <br />