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APPLICATION FOR PERMIT © Wi
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> 1601 E. HAZE'.iOl l AVE.. STOCKTON, CA
<br /> Telephone (209) 466-67811, NOV I
<br /> PERMIT EXPIRES 'I YEAR FROM DATE1ISSuED3 p+
<br /> 4. : ,£{}t, }•3,v>. t4y>; .> � �> 4MElV� l� Hi ,
<br /> (Comple•ta in Triplicateb ,t LT
<br /> F ERMI /S RU!`CS
<br /> Application is hataby made to the San Joaquin Local Health District for a permit to construct and/or install the wo�tc iem n �
<br /> '`.itfe in Cornpliana3 with San Jvaquin:County'Orrlinance Ho.540-for sewage or No + . Tlrrs.applscattgn as
<br /> x Local Health Distric:t., .+ x -1862 for well/pump and the Ruand R
<br /> lee +ygi+fauons'of tris San Jaaquin
<br /> Job Address 73 A~ + /. �, ry .%fir 4Y .iY 34' :fSw Li✓ Y1tf v M �q1 ii
<br /> I Crty Lcsx Size_
<br /> Owner's Name ! Addr�e� Phone
<br /> Contractor Address s m. a �(
<br /> 6 License No. f
<br /> t
<br /> TYPE OF WELL/PUMP: r. .� , NEW WELL ❑) WELL:REPLACEMENT ❑ DESTRUCTION
<br /> `.PUMP INSTALLATION ❑ SYSTEM REPAIR ❑
<br /> :. OTHER,
<br /> DISTANCE TO NEAREST:. SEPTIC TANK SEWER-LINES'
<br /> LINES DISPOSAL FLD. PROP. LINE
<br /> - - - :
<br /> FOUNDATION WELL ,
<br /> - AGRICULTURE __fit L _.�,__- OTHER WELL PITS/SUMPS -,, s �
<br /> INTENDED USE , TYPE OF WELL { PROBLEM AREA CONSTRUCTION SPECIFICATIONS _,�•,;t ��, -�`" r
<br /> C?Industrial T' ❑ Open.Bottom ❑ Manteca 'pia. of Wr l! Excava±ion - Ma b-
<br /> Dia'of Weq Casing T
<br /> C) Domestic/Private :❑ Gravel Pack ❑ Tracy Type of Casing_ t Specifications
<br /> ID Public ❑ Other C3 Delta Depth of Grout'Sea! Type of Grout._-.
<br /> i_; Irrictlon —Approx. Depth ❑ Eastern : Surface Seal installed by "
<br /> i Rapair i/trark Done 0 Type of.Pum ' —
<br /> p H.P, _ State Work.Done-
<br /> , YNeti Destrractior, ❑ Wel! Diameter Beaking' Material ;'top 50')
<br /> _ _ Depth Filler Ma#eriai
<br /> F' }'4'l?F,'C3F Sl FTtt WORK: NEW INSTALLATION © REPAIR/AODTFION UESTRUCTION ❑ (No septic system pertnit#ed.if po#riia mwer es ,
<br /> available.within 200,foeo
<br /> Installation will aervt�:. Residence A._Commercial Other, ?: .
<br /> Number r.,f.!iying units: II _ humbePof Ciybe4rooms �[', 'lie.araclef of soil to a depth of 3 foet:
<br /> . .w! tiw/a• Ott g.
<br /> -f..__ ... -•-- Water tnhle'd% t
<br /> SEPT!C TANK P - - ;
<br /> ❑ TyF,a Fuifg ---- - _ Capacity..----..-.....__ate.-..No.Cornparlmentit-'
<br /> SyKL'a, l-REATMENT PLT. LT
<br /> Method o' Gispolml
<br /> dislo ;e to nearest: Walt.- -- Foundation
<br /> �-_, _ Property Line
<br /> t f f f hflNG LiNF. LJ No. A Length of lines _._ � �r y � ���� `'7 �'"`
<br /> ! ngth/size-
<br /> FILTER HE:U � eat."}
<br /> Distance to nearest: Foundation_ Property Lind_ .
<br /> SEEPAGE PITS ,,� Depth Size
<br /> _sumps Distance'Distance to nearest: Well Foundation Property Line
<br /> DISPCISAL.PONDS ❑ t i
<br /> F.
<br /> "l.f«rebs certlfy 4har i 7+ ve prepared ltiig,apglicnlioq,end thai tne-yvrlrk will be(lone in a ccsraan �t r4itit yen ioaquin cnuttit oni!narrces;stats Iavr$ arrrd-��%
<br /> F r=ales Intl tos�ulat ane Of the S�jn Joaquin local Health District: { , p
<br /> 110n4e uwrser at licensexd agent's signature certifies the followi!ig: "I certify that in the performance of the work fpr vvbich this permit 4 issued,'!shag not �
<br /> iy!alssy D6V oerson in such manner as to become subiert to workman's compensation laws of California_"Cona"tof's Kiri.#f)or sub-contracting signature i
<br /> c rxrfiea Ilia fofir�,tiing:"i cerin that in the performance of the work for which this permit is i&-wgrt, i shall un 1
<br /> ,tin IRwo of Ca-41,01711 a lorry pe,seas subject to wnrkman'c cosr�ensa- i
<br /> �,
<br /> R k
<br /> Tl-,e.e stir annz�.sr c' for Inspections. Complete draw ng c,,letiersts d
<br /> rcilrS$'.l _.r, rr .�: .,,.� !•,,,�-„c,:...• ...... Titlri ''! l�1
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<br /> }' Appllcatign qr, r� r. w
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<br /> PIs or Granit In"ctiari
<br /> - ;ate _ ld Final Irr.'peatiort trey!- l� ^pate
<br /> A d tlonal+Cafnmvnts: t q
<br /> l' Stic +I + 3.-. ,..i^"❑ Lodi'. 3ti'S-3621
<br /> i ra
<br /> /trri�;r,aa ti li tam 38 capias to; Er AronrnentM Health Perm°t/SaMoea Hazelton Ave., P.O. Sox 2W% SM., CA 01
<br /> �tiVFQ Ardl)UNT DUE_ Af OUNT KE IT its �� Ci�ii�
<br /> t4tCEiVa'J.6Y • t DAY �i'EftM,'r'ldfy.
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<br /> .. t7 24 e'1r,
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