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rr t <br /> nr <br /> r«1 tr A- <br /> - r � �Lfi3L (t PA tt5tl <br /> 4 <br /> APPLICATION FOn PERMIT <br /> SAN JQAOUIN LOCAL 'EALTtl DISTRICT S <br /> ' 1Fr01 E HAZEL—PON A% '- STOCKTON CA <br />{ ` TLlephonc (209) 466 6781 <br /> PERMIT EXPIRES T YEAR FROM C1ATE ISSUED 1 <br /> w --- ICorrspIcj( In Triplicate) 7 <br /> n,pion 1 Ocal Heal t Distr+cl tot a permit to conslru,t"/Or~311 Ir"'work here"descnbcd INS epOlKatron Is <br /> Apolauon m M ehy mad"tp the'An J <br /> mato rn compl,a ice with<.- Icaquin County Ord,nanco No 5e9 for sewa{rt who 1[36 Igr.y„rtvpump and[tu Rutes And negula wns of I"San Joegsrn <br /> rUy!`A,',..,4- rid <br /> � Local flrallh DeS1i Ki <br /> s 10 7 <br /> 2iir - It_J f ✓� r. { rhe r,Sy rZI 1n Lot Sze PM <br /> Jos AAdrrss ,—. -�+_- ♦� �_`_�_�� �'� .. J <br /> Phone <br /> Owne z~lame Add,ess� Li <br /> .,vi•J1�4 '1 JL�� r .Vi"�'�L�.ti3e..11 SC�(A j�-7'1���45 rJr "yY Z <br /> Pham <br /> Lrcensf• NaL..1�� <br /> _ pnllacta _ <br /> - TYPE GF WELLlPUA1P �W LVELL C1 WELL REr LAr'EMfN7 C DESTRUCTION fa <br /> w— PJMP 114STALL4T QN {] SYST�Er.�/j}7EPAIR Cl LfJnTHER �jC(.S. <br /> t SE\tiER LINES A 1 DISPOSAL FLD._15CL PROP LINE <br /> ntSTANCE TO NEAREST SEPTIC TANI <br /> FOUrdDATION �, r,AICULrJRE WELL n IiEri WELL..II>=1-- PITS/SUMPS <br /> TYPE OF wF'_L PAOBLEt4 AREA CONSTRUCTION SPEC1rILATIONS C <br /> INTENDED USE �6 r-r <br /> s Ma of Well Cas.ng <br /> Cl Industria! ❑Open 9n+to+r CI Mantrca Dta J1 Wetl Esea.alion <br /> Type al casing- _ Sp1]. <br /> 3omcsNClPnvale ❑ Gr" Cl Tracy g� Specification. /T _ I <br /> i 1 PvD',c <br /> -Othri l]elta Deprh of G+ou[ ScaS Type of Grout <br /> c <br /> t I Inlgation t—4?F ptn y a Din maith �I I Lan Surlacu Seel Insreliod by <br /> .te <br /> Repair Work Done L3 Type of Pump — —_ r —���_ State Wo.k D %a T_ r <br /> Well Destruction Wett D,ame[e, Searng MJ'li,1.1{top 501 XJ• <br /> Depth Finer Malerwl IRelow W I J <br /> u <br /> 'YPE OF SEPTIC WORK NEN INS'ALLATIOrJ I I RL r'AiR/ADDITIOr1 I 1 OCStAUCTION I I (Noavailable <br /> system pprnetted d public sewer rs <br /> z &vada able bte w+Uun 200 fee!1 � C <br /> tnsravat,or+wta servo Residence_— Commerc"i^ Olf,er <br /> ry� Number of lrv+ng units Numt�er of bed,00ms _ <br /> Water table depth <br /> Character t,f soil to a depth of 3 feet <br /> CaI acnv _ No Ccmpertmenrs _ <br /> SEPTIC TANK L7 TypelMlq --- J 1 <br /> Method or Desposal <br /> PKG TREATMENT PLT [] v <br /> Owanca to rrar'-.l LV-l1_ — Foundation Properly Line f <br /> Na b e th u!ones Total length/sue __ <br /> LEACHING LINE Cl - reg --� ` <br /> t r [ FILTER BED Dr_tance to nr est VJMI _ Foundation Properly Line Y <br /> � R— ,., Numtxr e <br /> SEEPAGE P TS r ] Depth S'i° <br /> Ll Distance to nearrat Writ F0,141.0. Properly Line <br /> SUMPS <br /> DISPOSAL PONDS -Ale ,� <br /> I hereby s, rti'y[hal I have fuepared this app6ul,on and that the wprk vvrlt be done in nccordanct with can Joaquin county ordwnces • lam and h <br /> rules and regulations of the San Joaquin Local iieahh Dnu Ktt <br /> Home owner or licensed&peril s signature rmtrftes The 1,Ao.vrng I cart fy that,n Ihr pntiormanCe Of the work fog Which this permit Is awed 1 shwa f+01 <br /> Drr3pfoY any 1?x»n in such enenner as to bOCArt+e subject to woikm3n s cornPensatwn Iaw:P of C&Idofr" ConiracW%hiring Or kub-contracling W nature <br /> cerld as the focowing I Certify that rn the pertofmam a of the worth for wretch this per,_1 is risnied I shall employ persons c.rbject to workman s COrnpensa <br /> lion laws of Cai,fo,nut ' <br /> The applKar�7jnusl II ror all royu ifinspectwns Cornril�re o awing on reverse side 1 <br /> // r? 1 <br /> Titlea[C �"' f <br /> S. d X /�- i1 t <br /> FOR DEPARTMENT USE ONLY <br /> 4ppllu[Ign�c <br /> C.�}(f�s- Da+� rinpl Insnucton LY Date <br /> r Prt or G[Dut Inspecdnn b- — a <br /> S <br /> i <br /> t Addn,onal Comments <br /> 0 Sik ALE 6781 iJ Lodi 30 3G71 C,i 14arteea E1371¢ CJ T+aeY 9356385 w <br /> Appreanl llelufn all cnpre:to Envuonmen,"I Heeltt, neimnlirrv,eus i601 F ltnrution Ave P O 130r 20'1.3 51k 4A 95t01 <br /> r <br /> Cr—r PIP 11y VA1E PEt 1,010 NO <br /> - FtT AMOUNT Dt1F Af 011P.11 F I i't'ED CA S, <br /> INiO <br /> L— °` oa 1017 0_��77� <br /> t I <br /> Ji <br /> l <br />