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:4 u <br /> A r <br /> n <br /> APPLICATION FOR PERiwrr <br /> SAN ,JOAGUIN LOCAL HEALTH DISTRICTL1 f!-� l`7" _fl <br /> 1801 EHAZELTON AVE., STOCKTON, CA L' <br /> Totephons 0 )405-Ml <br /> PERMIT EXPIRES a YEAR FROM DATE ISSUED' ��•T �, ' �° <br /> A <br /> ;(Complete In Tripllcatel' N,RJ��QUI <br /> i ApPNaWon is N.rob;i'rcAd.to tis Sin J. Zr N <br /> fmade h aompBanaa wilK San 1 %Mn Loaf Haft Dlabkt for a peimit to cc.tstruot and/or install the work herskn is <br /> Local Flarfth D6ulot�t �anyntutce No Sig waps for twa Ho:168'l for rr.9/pump and the Rules and Regulatfone Joaqu _ <br /> Jab Addbas , xs mLot uh.c{IL� Sill <br /> C Owttat'a flarrto ' r <br /> _ s <br /> Phone €{ �0�,�., <br /> Ccnvaetor'a Netnttr`' License No. Phone ? +" " <br /> rat <br /> TYPE OF P r WELL REPLACEME QESTAUCTiON ❑: t rC - <br />{ PUMP INSTALLATIONSYSTEiN REPAI OTHER ❑ <br /> DISTANCE TA NEARk-TAT �EPTIC'TANK SEWER 11NE5 DISPOSAL FLD: PROP.'LINE 777777,-. <br /> 4� <br /> =n a irFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SLUMPS , e <br /> Cyd.. 1R <br /> J 1NTkS►IDED USE TYPE'OF WELL PRO, • AREA CONSTRUCTION SPECIFICATIONS !� Y y,h t d <br /> Zx r„ i <br /> ❑btduetrial ❑'8ottorn Dle:of Wall Excavation ie:;af WeII Cawing <br /> 3eIPrMts Peck_' ❑Tracy Typo of Cad i peciflcatiorn <br /> ❑Pub9c <. F ❑Other p pelta - <br /> Depth of Grout Seel Type.of y` <br /> ❑irdgatkn - _ �.Apprcx Depth ❑Eastern.. Surface Seal lrtatefled by >5 <br /> Repair WorK DO" G' Tom+;M Pump _'' H.P State Work done <br /> Web Dareructlort ❑ Weq Dlattater' „Sealing Apatsoal stop 50'f <br /> x Depth Filler Material(Below 50') <br /> TYPE OF SEPTIC WORK NEW INSTALLATION 0 REPAIR/ADDITEON❑ DESTRUCTION❑ Mo septic system permitted if public sewer is <br /> available within 200 fast.) �r n <br /> ��rrtion wN serve <br /> Residertee Commercial Other <br /> of living un(os Number of bedmoms t I <br /> Chatactsr of aa#to a depth`of 3 teat: Water table depth_ <br /> FS f rl <br /> SEPTI GTANK ❑ Type/Mfg Capacity - No. Compartments. <br /> PKG.•TREATMENT.PL.T ❑ Method of Disposal ice. <br /> Distance to neerast well Foundation Property Line k <br /> LEACHING <br /> LINE'­­;..LINE ❑ •No..&Length of Into• Total length/sUll .J <br /> ❑',:Distanca. <br /> FILM BEI] to nearest.. �'. Wall ' Foundation Property Line <br />' 9 <br /> 1 <br /> I SEEPAGE.PITS ❑ :.Depth Size Number <br /> .. <br /> SUMPS' ❑. QittertcA to nearest:., :Weil Foundation" Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby'eertify,ettat k hair@ prepared this application and that Ow work will be done in accordance with San Joaquin county ordinances state lovvo and <br /> rules and reoAr done of'1he SanJoaquin Laasl.Heahh District. <br /> Harts wtnteror fieaetsed agertYs signature certifies tits foNovring:"I certify that in the performance a1 the work for which this permit is gsuad,I ahe9 not <br /> arnplay'any parson in-such marurer as to become subject to workman's compensation laws of California."Conaactoes hiring or sub-contracting sronature, <br /> r <br /> osrtHiao the folowirp:'•1 ca'tify tftat m the perfomar�ce of the work for which this permit is issued,k shall employ persara subject to vrorkrrten's eorrtpata� <br /> tion Iowa bf,Cedf, "lip �I : <br /> The Call}or atl u' irupaedone drawing B Side. t <br />[5 Srgrted CC Tae: Date: <br /> j. R DEPARTM. SE ONLY <br /> Application hY Datil 4—�� Area , <br /> K yid <br /> Pia or Groat Inspection by Da .Final Inspection by Dass <br /> Additiornil'Corrrrtenh..a: . - <br /> Mantam''8?3 7104 T <br /> ❑St#'''IEtLB)$1 _❑Lodi...393362.'-' a7 C, 83ki6366: <br /> ra4y <br /> Appieant Return all eapbs to k3tvnanrrlertel Health Permit/Seances 1tia1 E Hazehon Ava.,P.O. Bax 20t1B,Stk.., <br /> tk CA 95201 <br /> AMOUNT.DUE AMUNT REM TTED RECEIVED BY DATE. PERMIT NQ <br /> 1.20 rasv truss, _3 0 o F3 0� /t o! - 311_ <br />