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<br /> -.:"r } APPUCATiON FOR PERMIT'
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<br /> SAN:JOAaI!!N`U]CAL HEALTFI DISTRICT.
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<br /> fI. 1601 E.'HAZELTON;AVE., STOClCTON, CA
<br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED
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<br /> ;�s. .APp "I.. abY made to the"San Joaquin local Flodth.Diatrici for pemrit to CanatrreCt andlor ' : i;�rprk,farreYt deacrbad:1111a appiCeCferr I.
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<br /> " z,m� ,f made iA QOrnpiMtOe wish San JoagWrt County Ordlrtrrtcr No.So for-- g-or No 1862 for wWI;Nm h Rulesand Raylelaatlatl.of the Sen Jae*dll h
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<br /> tr '� �OwreeraNance �,�-��,Li J'��.�n�r.d eCf9� /U YF. TPlwne ,
<br /> ,, CurtraCtct. ' ` ' address ;ZA20"J /.l.-LA��Ll Conn NO 8'�/�>F[tale k
<br /> s u TYPE OF WELL/PUMP t t EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION II ri w I
<br /> i 1� a c sf `. ; PUMP 41V TA ON ❑ SYSTEM REPAIR �; OTH13t ❑ x a ` j
<br /> f ," ?11�.�DISTANCE TO NEAREST SEPTIC. NK I' L, SEWER TINES -' DISPOSAL FLD i PROP L1NE
<br /> a RFT,�r t fir ". . r FOUNDATION(t-�' y_ "AGRICULTURE WELL OTHER WELC�� PITS/Si1MP3 �w1. fi
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<br /> L a7�*INTENDED USE TYPE aF 4i1'?k-, aBLEM AREA 'CONMUC77ON SPECIFECATIONS f11 il r r r i
<br /> 11 `ty ❑Indwd WT. 0 Open Bottom 'CQt Dia.of.Wei Excavation Dia of Wei Caairtg" t 7
<br /> s sf II Damatk/Private ❑Gravel Padc ❑ t Type of,rasing. SpedReatiorn
<br /> PubUc ❑Other; ❑ .Depth of Grout Seal Typs of Grout 'r
<br /> ter}_,` a Irrigation -' _Apq`ox Daptte"�jQ East _' rf►�os Seal livttalled by �k
<br /> Q, Y Rttpak Work Done ❑ 'Type of-Pum11 .1 Ip S (� H P.1.` ` State Work Done 0//L1 5���aL-f1 E.4' , ,"
<br /> k:'_L Weil Dnstwction ❑ Weli`Diameter ,. rHip.Maisriel itiop 50'1: �,�k/T/JA��' S�'.eE�J�I �=94 r �
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<br /> t r - ,. Depth ti y Allatarial IB6101Y 5fll J'l�L n/C,�/OL.D /75, .
<br /> I .,f TYPE OF SEPTIC WORK NEW INSTALLATION❑ REPAI ADDIT`ION'IJ DESTRUCTION❑ (No septic avow. pemrtoed if public aewa is F i
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<br /> ylrtan}Isrion vknll sorra Reardenee:_,. Coautreneial_. _ Otlipr _ _ y" ''- L�1^ `� „ .
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<br /> r s x�Number of fnntlg a1.mts Number o}bedrooms ' . u
<br /> "' Clt�ractrr of sal to a depth of 3 feet W
<br /> � t ` SEPTIC TANK ❑ Typo/Mfg t t Gapacm, NoCompd� z
<br /> ,, k PKG TREATMENT PLT ❑ `' Method of Oi�loaaL3":
<br /> r�` , � Dlatance to nearest Well Foundation Property Lina i
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<br /> ,: LEACHING LINE ❑ No 8,arigth of lidos Total length/ ' ;" 5 ;
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<br /> ` FILTER BED [2r_Diasar�ce to neareaL We0 Faendaticn Property Line k
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<br /> {. SEEPAGE PITS ❑ th' Size Number I
<br /> SUIliMPS ❑ Distance to nearest Well' ,F+idetion " .Properrf ane
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<br /> DiSPOSA!"PQNDS ❑: '. - �. p t
<br /> I hsreby.'ceriiiy;hat l havd plepered djjS application and that the work w 11 be done in.accordance with San JoaquigCaurtty ardatatleas;.atada tr�ra;acrd
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<br /> nrlar'atd,repulstions"of the.San JoaquiwLocal Health District. `it
<br /> Home owner rx rweneed agent's'.siyrrature certifies the foio+ving:"i tanrly ythat In the performance of the work for wfdeh this gem*is iestisd,i tilai n a
<br /> ampigy.aery person in atrell manner as to bscarrte subject m workman s Ia+ra of•'rl'rfamia."Contractors or cab eantraetinp '
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<br /> csrdFies the fciowng cer*that in the periormamoe of the work for rmit issued,l shall employ pereorre aubieat to fvorkrreert s oorrrperai; k
<br /> tion laws of Ceiifamat _ is f ti c;ww f
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<br /> The applicant si bores Compkn dravra►g on fevferae �y r #
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<br /> F FOR DEPARTNiEM USE ONLY + �
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<br /> 'ApplicatkmAccepted. Date 'firer
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<br /> ' App4carrt Ratum er copies.w.EmmonmenL_Heahi►Permit/Sarricea t8?7 E.Hazelton Ave P.O Boa 20D4 Lf .Stk'CA 9fi20t;'
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<br /> INFO ''A�AOUNT OUf AMOUNT RELttT7ED, N RECEIVED BY DATE:: a PERMIT'NO-'
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