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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH EI <br /> DISTRI <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ���W <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSU OCT 17 <br /> (Complete in Triplicate) N41ENTjkL HEALTH <br /> Application is hereby made to the San Joaquin Loci Health District for a permit to construct and/or instal This <br /> Mede in compliance with San Joaquin County Ordnance No.549 for sewage or No. 1862 for well/pump and the and Regulations of the San application <br /> oaquin <br /> Local Health <br /> •District. <br /> Job Address L/_-!_/ City Lot Size PM <br /> Owner's Hart~ �. Address Phone <br /> Ca", for gzz�. AddressO . �'LLicense No. Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 'INTENDED USE :;.:: TYPE OF WELL PROBLEM AREA^ CONSTRUCTION SPECIFICATIONS <br /> O Open Bottom ❑ Manteca D111.of Well Excavation Dia.of Wet Casing <br /> i rpoirnsbeJPtiwtt _ O Gravel Pads ❑ Tracy Type of Casingspecillications <br /> 11 PUM .O Other <br /> 171 Delta Depth of Grout Seal' ` Typ11 of(3rait <br /> `f+r1 T Mri�tion - `� Approx. <br /> Depth^ I I Eastern <br /> Surface Seel Instated by x' <br /> ' Rap*Weak Ooar. �!. T11ps,of Pu <br /> mp H.P. l�+�� <br /> � State yy ne Work Do ... .: <br /> ❑ 'WM Diameter Sealing Mom"Itop W) <br /> « ter,, -,"•�.Y.Dep� Filler Material(Below 50'I <br /> r TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l i DESTRUCTION I I (No septic system permitted if public sower e <br /> available within 200 feet) <br /> ° �r va 11aero RvdMtcR'_ COarrterCiel Other ca{ 4 <br /> unkK Nwt*w of b .... .� <br /> t <br /> "�Clwract11rof sol Is a depth of 3 late WatK labia d11pdt <br /> SEPTM TANK. « :.O_Tl! CM>scKY No:ComparuneMs <br /> PK TREATmw!-PLT 0 Method of k. <br /> •ta �` :"" , ..M Olathe to W44 <br /> •�,.-' °s. .5 "' �.Fottrtdstiort• Property.Line <br /> -LEACHLME ' O ��Na.i LsrrgMi Total krrtgth/size :< 77 <br /> RLTER 01ED `-_~ OOtittirtca IAAe� <br /> �:fE:�* "_� �• t<, llsatast:' �:.._•:�Fa"atd�ii°" <br /> Property L"'° <br /> >,� ,h.,',..ter + +' ,•�•. i .. <br /> SEEPAGEP[T5� '�4t t I DapYa f '' <br /> NUfnr" <br /> ph 0 Oitpnor!b Ila11l11 Wall Fouralatlon berProperty <br /> 'W77fi L <br /> im <br /> �Q"1` <br /> `` 1 hNablrhewdfy tbsc UtrrpwpeMd tit4 app/oa�g{an�a�ad OW ft'work vA be dexo in aceor dwtt rt Math San Josgtrir►ca+rgY weignoee:wts 4w^and <br /> rrisand tprrlelba�oE Y111 Sea Jlesptrit►tree11C Hsrtit'ptltriet � sty y':•- -� <br /> Homs owneratc tio11rt1111d a�peut'a s> utn oareMies tM :"I=W*W b dw pwf mm rm of the work for which We permit is band.I a1W not <br />, ' r ";entpiolbsnlr p11rsai 111111rt:11 awtn11r as b b11ooats t b wotfttrtstr s oonprwtbn Ims of Gtfarre."Contractors wing or eubcoraseft dp mua <br /> a11rtifi11a ells foiowrYtp:"1 osrlify that in tlt11 p11riotrrt11rtcs of the workfar uAticA this p11rmk is keued,l shat ernploy pirsorte subject to workman`s oomperw- . <br /> tion Ishii of Catiorrt .. <br /> T'he IF t arNt eaf focal mlIteked inepsCdorts.COM010b drswkV an <br /> aide. <br /> Signed <br /> ." <br /> Dam: <br /> FOR PEPARTfiIIENT USE ONLY <br /> Application Accepted by Date <br /> Pit or Grout Inepsction by oaa Firth Inspection by Data <br /> Add kwW Conwnents: <br /> a Stk 48644 ❑ Lod 3E-mi ❑ helloes >)IZ;i-7104 O Trecy 8364= <br /> APPtcant-Return at coPWs to: Emrironmemai 110111th Pamit/Swvim 1001 E. Httteltorr Ave., P.O. Box 200®, Stk., CA 86201 <br /> MFEE <br /> 0MA <br /> / DtMrf DUE AMIOIJNEON?T�T RCASH RECEM BY DATE P61MIT'NO. �- <br /> ..EM M36"W. /as) <br /> EH t17e <br />