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r c� rte" ?y.a , . • .. y�iA'1"� N ! PERMiT bra„ _ ' f-V 'a' --$AN .O,A�Il' �tOCALH$ALTH DISTRICT HAZELTO:N AViy. STOCKTON CA �-Y,r} ��i r ?4{ Yd et+, }� tz '!'4..y t� _ � e �rGW1YW'Vi01 i- ,•'#�^t, .. c +yck IYEAR FROM DATE ISSUED .s� . +� � s �<Y r § r., �' y i C$�hpl6te in Triplicate)., _ ,+ a „ t/reDY':111wili 0.0111i' �J !dr tl.pertntt to construct and/or install the work herein daaCt '. 18pp�t3orri= Mw1pe pt No 162 for won/purnp.and the Rules trod Rsge+�ititirt! pujn t 4 k.. " �` t y'k• -ALF u 7 1.�i ti}� tS.-0r d All i �' �,2: � b-�:s?" 3-.'."$r f t f+A r w-"` r.• `A .r ; - ''c§�' ¢3- e .Z ..4 F t• z .` .f } .. "!"�' �ac _',:'4 .Yat �r .ya rt r10� iddieia Cery Lot Size �w �` :. *.ire ,�y� !�{',, y+• - ». ��•..1`9 •. 8{ � i5? -l �;"3; T�p "i I YC - F?' 1 '--`�_�w•F r � - ''l" '�.'h�` _.�:�5�" - 6 Y a. ti R K , ' std f wl q g �t x ? conlf tor.' .r e `.Ad�r�S)i' sa a License No. plloplc TYPE 0F,WELL/PUMP ,,NEW WELL ©, 5 . —WELL REPLACEMENT ❑ . DESTRUCTION 014 r E h _ Pl1M Ikil ALLATION ❑ SYSTEM REPAIR`O' OTHER ❑ M 1, , a DISTANCE TO NEAREST. SE�'TANK i '` '`SEWER LINES DISPOSAL FLD y' FO 'ON, AGRICULTURE WELL,. A ER PITS z t INTENI)6 `USE nTYPE OE WELL PROBLEM AREA r CONST C-CIFICATIONS I` �,; F❑ lrldntatrial ❑:Opari'Botsorn Mar>tepl of Well xn ❑ D o mest i c/ P r iv at e ❑;Gravel Pads rf `� �Typb of k •' SpttctTlct�onllr' E r-� trnlic n other n �� faith of seat v ofit3ratir''' R�T j �' -x PF sa tHr'a�t �f '""�„�. ,�"°'+.rti+as,.... -f. .�"..r S'r�.r ;t. .t �s•a� 11tgatron k Depth i 1 Ea�twre a a31+fae1� , `e. t s "-, 0 7r ¢ a.G Repan Word Dane Type of Pump a �t r�#1 p ��t;taai#Mork Dat+s �u N� . wen n ❑ Well Diameter top left r 'Seaslfne Mal I Depth �IIetAaterial 1Betaw 5I1rI• v=' r { TYPE OF SEPTIC-WORK: NEW 1NSTAi4ATION I I�--REPAIR/ADDITION E I DE TAUC-TtO ;(No septic•syatem•per*fitted rf pu6ltC se�w4i Y availahle within 2t>0)eats) y Iratallatwitiwill serve: Residence CominerClal'_"Other "' �" Number of living units: Number of bedrooms fer of soil.to a depth of 3 faet't-___. _ Water table depth,A I TANK ❑ Type%Mfg' capacity— 4- 40.'COrnpartrrlents O4 PKG. TREATMENT PLT.❑ Method' Disposal Distance to dearest: Well Foundation Property Line -. . 41. tEACHFNG SINE ❑ Na:A.T1 enoth of-lines _ Total length/size FILTER•8ED �•.` ❑ Distance'to nearest. I Wafl Foundation Property Line SEEPAGE PITS I I Depth Sim_ Number ` SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS © ) I hereby certify that 1 have prepared this application and that the workwill be done in accordance with San Joaquin county ordinances, state laws,and rules and regulations of the San Joaquin Local Health D3trict. Home owner or licensed agent's nature certifies the f �' g sig following: "I certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ yppersons �subject to workman's compensa- tion laws of California." V The applicant ust call for all required inspections. Complete drawing on reverse side. ' Signed • •�,�.r#IYG, Title s._'"`` `* \ (� ' • --- –1 –_ .._._ Date: FOR DEPARTMENT USE ONLY Application Accepted bY. # L '�' Date_ . ' Area s Pil or.Grout Inspection by_ l ` _ Final Inspection by d -C>CcI_ .Date !� Additional Comments: :0 Stk .ass-Ml C7' odi s 3e�3szt 0 Men F'fi23-7104 ❑Tracy 836-a�5 f Applicant Return ril.coples.to f npironteterltel Health`Pemllt%Slrrvio�= lwt E Huse[on`Aw..; P.O. Box 2009, Stk., CA 9ti201 kE INFO FEE AMOt1CK 8 NT AtJE,) AMDUNT.,REIiAIT7EQ :'CASH %' RECEIVED BY DATE PERMIT'NO _ �r� ♦tiH la-.�41tItV 4Ie 01 �, r � �a""�'�r 1 `L ;+ ti, r, 1 fi a,F �f