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w7 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT FZIECEiVVT c <br /> 1601 E. NAZELTON AVE., STOCKTON, CA <br /> Telephone one 1209)466-Mi Er;. <br /> PERMIT EXPIRES 1 YEAR FRO t7 DATE ISSUED <br /> (Compleb In Triplicate) fi+j ONKE—NT-9� ? <br /> A p P,tntTjS[L'%ncl <br /> pplkation h hereby made to tM San Joaquin Late!Health District for a permit to construct sadiCr Install the work heroin d6ncribed- <br /> meda in compEar ca With Son Joaquin County Ordinance No.549 for T►i*appi€cat€on is + <br /> Local Hesith District::: sewage or No.i1i62 far well/pump and Has Rules end Regutatkms of the San Joaquin <br /> Job Address .. 3.i✓i?� f i�,-- �'�'^= �Y L/t CJtSr Lw Size FM <br /> Owner's Nom Addresses �t rA'T � <br /> J. <br /> Phone &7.0 <br /> Caniractor_. ._ Address <br /> License No.&2Z&53�5- Phone <br /> TYPE OF Wf Lt/PU P:3, HEW WELL WELL REPL4 MENT ❑ DESTRUCTION Q <br /> 2. rtr1 PUM INbTALLATION Q SYSTEM REPAIR ElOTHER X ln,.,,,h.,rr <br /> DISTANCe'� AItpsT- SEPTIC TAMC SEWER LiNES gra r DISPOSAL Ft D. PROP.LINE <br /> ". FOUNDA.DN AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLI M AREA CONSTRUCTION SPECIFICATIONS <br /> Q lndu ttl:I ❑open 9at66et Q Msa�teta Do.of Well Excavation Dia.of Well Casing �rtr <br /> ❑001110Ctic/Private gGrawd Pack Q Tracy Type of Ca o€ L Specit€cations <br /> 0 PubJlc ❑Other 0 Debs Apptox.Deth Q EDepth of Grout Seal _ �-1ot Type of Grout <br /> f7 Irrigation _ — pastern Surface Seal Installed by 4 f <br /> Repair Work Dona 0 Typo of ourrlp� N.P. State Work bone <br /> Wall DestrucHory CI Well Olu-'Atej -I ?� SeaEing Mat®rlsl itop 60'} — <br /> Ath F€iJer Rfster"st{Below 5w) <br /> TYPE OF$ <br /> EPTIC WORK: NEVA JFi5TALlATiON❑ REPAfR/A07lTIGV❑ OE51RUCTION Q INC septic system permitted N public sewer is <br /> eva€labla within 200 feet.} <br /> f Installstlort wAi serve: Residence Carimmorciai Other_ <br /> Number of Being unite: Number of bedrooms <br /> Char►.ctet 6f 11611 to a depth of 3 feet: Ylater table depth <br /> s SEPTIC TANK ❑ Type/Mli Cspac€ty - No.CCmparunsents <br /> PKG._TREATMENT PLT.❑ Method of Disposal <br /> Dittencd fd Wr"I: Well FCundrtion Property 1 fns <br /> f <br /> LEACHING LINE Q No ®Lwhith of Rhea Total lengthleixa i <br /> FILTER BEd ❑ Distend Ir ftapft Wel! Foundation Property line <br /> I <br /> SEEPAGE PITS` Q Depth Size <br /> Number <br /> SUMPS i , IVA <br /> b Disun"tQ htiafbst: Wetl Foundation Property Line <br /> DiSPbSAL <br /> rules i horob <br /> Mon�ltsva P lid.J {Rot,and that the work will be done in accordance with Sen Joaquin county ordinances,stent taws,and <br /> t: 4oae'af the l3dro JOdq,r6w" <br /> Naelth District. <br /> H6nie oaint9# botr id slftrnt'1the following:"I car*that In the performance of the worn far which this permit le lined,I shat!not <br /> e�y MY isarjo irl 4ucN mefvtl t ab subject to workman's compensation Is"of Cafifomia,"Contractor's hiring or*ub-contracting aignature <br /> tion Ipvrs of f0ACs ,r c6rUfy that In*4 <br /> - dente of the work for which this permit Is Issued,I theft ampl6Y persons subject to workmarl'a compenea• ! <br /> E - <br /> I The aplPficftL <br /> ftAtine <br /> cell for I required pettfoIts Compiete drawing on reveres side. <br /> f <br /> Tide._6� � i '�nrryc37 Dole.. <br /> I FOR DEPARTMENT VSE ONLY <br /> Application Accepted by <br /> — Date Area <br /> Ph or.Grout f*fttlon b1 Date Final i f <br /> nspecdon bate <br /> Additionty Comments: l <br /> Q SHr iEIQ Q)8t Q Lodi 3i11J-301 - Q Manteca M7104 ❑Tracy 8364M -�— <br /> t Applicant Retum all copies to:TdtYkvetryNlftl Hoslth PennNlServices 1601 E.Hazoiton Ave.,P.O.Box 1009,Stk.,CA 06201 <br /> NPO PUNT OtlE AMOUNt NEMITrEn CASH RECEIVED BY DATE !'ERM1?'Ntl, <br /> Eft 14 IPEV.rI661 ^ rj.�4 <br /> ` EH N-76-M fv- 2A - <br /> j <br />