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- <br />' <br />! APPLICATION ^^ <br /> ~ ' ^~ -- PERMIT <br /> ` <br /> i ��J���O����Uk�W' ~ <br /> EALTH 7G81 E. AVE." ^^ DISTRICT— <br />| ^ ' n����|o� �VE . STOCKTQN[ CA <br /> Telep6one (209) 1 <br /> PERMo construct and/or 1 <br /> Application is hereb�madWtoj' <br /> the'San A" <br /> aquin Loral Health District for a permit t <br /> made in compliance with San Joaquin <br /> ^~^~ Health District. 4 *, '� n�Ordi�;��-,ance~~~�'°' vrm� `�2m,wew p--'11 -- -~^' TNs <br /> _ . application is <br /> _-t-.~~~°.dRegulations o,the San Joaquin <br /> Job Address q5 AC <br /> city� IT , <br /> 'Lot Size <br /> PM <br /> Owner's Name-.11-15T1,1111111 '14 C <br /> Addeess <br /> Contractor <br /> � <br /> . . Address <br /> E-_ _ =��� nepuxo ^ <br /> DESTRUCTIO <br /> PUMP INSTALLATION [D L] <br /> DISTANCE TO N8ARES SEPTIC TANK YSTEM REPAIR El OTHER [I <br /> SEWER LINES <br /> FOUNDAf'ION DISPOSAL FLD._ PROP, LINE <br /> nteca 6)a. of Well Excavation T <br /> � <br /> .[]'Gravel%Pack Dia. of Well <br /> 11 Tracy, f,I Tgoe of-Casing Casing <br /> El Public <br /> Specifications <br /> L Irrigation D6pth6f Grout Seal. <br /> Pprox. Depth EJ Eastern Type of Grout <br /> 13 <br /> Repair Work Done L Type�'d%f-pump H,P. Sutf4ji6a Seal Installed by 6- <br /> Well Destruction Ef Well Dia(hater State Work Done 0 <br /> Depth <br /> /'pspp � STRUcrION SPECIFICATIONS <br /> 0 Dome <br /> ^ <br /> - ..~ . � � <br /> Installation3EPAIR/ADDITI DESTRUCTION <br /> _~ ===�t Reside Pee Commercial vai ble . <br /> el <br /> Number of living un~^ . within 200 feet.) <br /> umber � <br /> of bedrooms <br /> Character of oi ----- <br /> ID Type/Mfg —' Water table depth <br /> SEP'TIC TANK <br /> PKG- TREATMENT PLT..F1 0.-Compartments <br /> Distance to Method of Disposal <br /> nearest: Well Founclati��k,�;7 <br /> Property Line <br /> LEACHING LINE No. & Length of lines <br /> FILTER BED 0 Distance to nearest: <br /> .well -----__ Foundation <br /> SEEPAGE ".S ' u oopm <br /> Distance to nearest: <br /> D"SAL PONDS F] n Property Line <br /> I hereby certify*that I ha�e prepare.d this application and that the ^ <br /> work will be done_InAcRq�rclance with San Joaquin CoUnty ordinances, state laws, and <br /> rules and regulations of the San Joaquin Loeal'Nealth District. <br /> Home owner or licensed agent's signature ceriiiies'thefollowing: "I certify that in the performance of the work for which this permit is <br /> ll <br /> employ a <br /> ny person in such manner as to becom-e-subJecito. <br /> workman's compensation <br /> certifies the <br /> mvnm"�o'following; signature <br /> - '~~~` ^�^"'��»»nonnom�»'��wnmmr,"mc»mm m�- - California."°"'""�pr» � <br /> The applicant `California.-.: � employ--is issued, I shall ~^^~'~~"�"" =w»mmwosoomneno� <br /> Z <br /> .call for all req'uired inspe6tior�;- Complete drawing on reverse side. T/7 <br /> Signed <br /> FOR DEPA MIENT USE ONLY <br /> Application Accepted b /-,- -1 <br /> Date Area <br /> Pit or Grout <br /> Inspection <br /> Date Final Inspection <br /> Additional Comments-' ate ' <br /> � <br /> 9- 1 �nte 823-7104 <br /> _ �. <br /> AppIicz <br /> e­t_ _ -`_- .^ . . <br /> .ff , <br /> � INFO MOUNT . <br /> F <br />