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: ' , i - <br /> `APPLICATION FOR PERMIT <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4;a <br /> O 1801 E. HAZELTON AVE., STOCKTON, CA y <br /> "Telephone 12091466-6701 <br /> ° PERMiT'EXPIRES 1 YEAR FROM DATE ISSUED <br /> j •' ..:_ �� r; F y� t..k� D ,..' ,.. r_ .y,{iyrMomplete in Triplicate) <br /> Application is hneby msda Io Mea San Joaquln Local Haft District for a permit to construct and/lir install he work herein described.This apppeation+s <br /> ectade in With San Jostprlri Countypnilnance Na..619 for sewage or N0.1962 for wall1pump and the Rube wed Regulations of his San Joaquin <br /> ,. Locel Henn Digt*t , <br /> w LAJdJob Address <br /> _ City .._ Lot 511' PM <br /> `Owners Nara" 7?f/ Add <br /> i. <br /> 4 rae Phono <br /> A <br /> Contractor <br /> a Z _Liccirse Fio.y $ e�_Phone M2 <br /> TYPE OF WELL/PUMP: NEW WELL a WELL REPLACEMENT t_I DESTRUCTION C1 <br /> PUMP INSTALLATION D SYSTEM REPAIR CI ' OTHER X�6a pet/w)b <br /> DISTANCE TO NEAREST: SEPTIC TANK.,,-- SEWER LINES � DISPOSAL FLD._- PROP, LINE ` <br /> FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS I_ <br /> NMDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IredwrtrW '" 1,Opns f3ott0en "❑Manteca . Dia.of Wag Excavation g _ Dia.of Well Casing <br /> ❑t)orrrestle/Private' 0 G. n M Patlr`'. ❑Tracy. Type of C"ngA9A—V Specifications <br /> ❑PUWc ❑Other 's ❑Delta Oepth of Grout Seat _ <5 d�__ Type of Grout qr <br /> ❑irrigation .._».Appr4=.Depth; .O Eastern <br /> Surface Seal Installed by <br /> Repair Work 0"* 0 Type of Pump ' H.P. State Work Done_ <br /> F <br /> Well!Destruction ❑ Well Dlaftww Sealing Material Itop 60'1 <br /> Depth Filler Material{Below 5011 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION CJ DESTRUCTION I:i Mo septic system permitted if public sewer ra <br /> l * ` available within 200 feet.1 <br /> Inataffation will serve: Residence Commercial— Other <br /> Number of adng rrAw Nw;bw of bedrooms <br /> Character of soa to a depth of 3 feat _. Water table depth <br /> SEPTIC TANK ❑ Tylia/Mfg r Capacity No. Compartments, <br /> PKG.TREATMENT PLT.p Method of Disposal <br /> OWtarce to rtParest: W Foundation Property Line <br /> LEACHING LINE ❑ No.a Length of fines _ Total length/size_ <br /> FILTER BED ❑' Distance to nearest: Well oundatiai Property Line <br /> SEEPAGE PITS ❑ x ,. .. . <br /> DepW 54 Number _ <br /> SUMPS `Q'.Distance'to meanest: WON Foundation_— Property Line <br /> {: DISPOSAL PONDS .❑ <br /> I hereby cagy that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws,and <br /> rubs and reguations of the San Joaquin Local HeeM District. <br /> f Home owner or licensed 999Ws signature certifies tics following:"I Certify that in the p9rformance of the work for*:,`ch this permit is issued,1 amll,gut <br /> employ"Prion in such manner as to heeoma subject to workmen's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> Candice the fallowing:"I certify that In the performance of the work for which this permit is issued,i shall employ persons subject to workman's compensa• <br /> 3° Ikon lawn of CaMorrria." .. i <br /> z The apppemrt MWAS11,01 ail Ons.Complete drawing on side. <br /> Signed x TRIa: _ /2-115-97 <br /> Date: <br /> R DEPARTMENT USE ONLY <br /> IL/41L �� <br /> PPib+don Ampud by _ DsteAre" �1 <br /> s Pit or Grout Ineps ftin btr n by�' r Om f e <br /> AAdditionalcommenceG+is` rift t) A M Ml �G-' <br /> i ❑Snt 4064M ❑Lo" 30-M ❑ � <br /> e71a, 117i*Cy <br /> Applicant•Retum M eopl"s to:6rnlrorMrrargM Health Permkel8ervias 1E01 E Htutle0n Ave., P.O. CCx 2009, Stk.,CA 116201 <br /> NafO FU AfMOUMT DUE AMOUNT III M RECEIVED BY CATE PFAIW'NO. <br /> am va-M law,v eel i -•� . <br /> FINS <br /> yy red�y <br /> a 40£A x+7 !fes-r -4;4,:r' <br /> �,.,ra.wira�i✓.3 .. arra .a.. :J�u <br />