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<br /> I APPLICATION FOR PERMIT
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> 7001 E. HAZELTON AVE., S T OCK'OeN. CA
<br /> TOephone {2091 466.6791
<br /> PERMIT EXPIRES 1 YEAR FROM DATE 1SSUC-D
<br /> -— (Complete in Triplicate)
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<br /> Applicatrun rs he,eby made to the Sall Joaquwn Local Heallh Dwricl lof a t•elm:I la construct anofol vislall 1'-,vnA he,e,n descr,bed Tf>•s ap#,cs::.tn rs
<br /> made m co,nphdnce wilt,San Joaqu-r.Cnua;y CJtJ nentc No',A9 for se�:vdqu or Nn Ili.2 for,ell'--p end Ihr 11"tes,6-1 Reg.141-ons I[he San Jadqubt -
<br /> L.Cdi Hcalih District.
<br /> ,.��y1 � ._-��L�v.r.C�(74'i�. 1�,�::'r�{1Cf7 /C��4•Y'�.�('-�,
<br /> Job Address /.ir'�i�-C•u�y>7 s- _r i,=Y__.....__.------. L.6t Sill —___ FM
<br /> /3r S 7
<br /> Own,:r's.'Jame __-_-. .____.- _..-._-_.� Address
<br /> Cbnl1lttci ,�� .1-1-i-.if-•.j/`•�I t-Q L :',I
<br /> e S S _(�_Y._.I._ � r�'�� '{zz lcelm! NJ.�.� .�- }-;_Phone�����
<br /> TYPE OF WELLIPUh1P: T NLVJ YJELL :t %'.'ELL RE PLACEI.IFN1 i i DESTRUCTION 1.1
<br /> PUMP It:STALLCTION SYSTEM REPAIR i.1 OTHER
<br /> DIFTANCE TO NEAREST: SEPTIC TANK SF%VLR LINES _-____...-.- DISPOSAL FLD.____ PRQP. LINE .�_ 1
<br /> FOUNDATION __._.._ ACRICULTURE:':ELL _ OTHER WELL__-_,_— PITS/SUM-;I _-
<br /> INTENDED USE IYPE OF WELL PRORLFM AREA CONSTRUCTIO11 SPECIFICATIONS
<br /> l i'lndusMal-- -� f,]Otien Rnuom , Manircu --- Ora.of Welt Ecce ca.nn _- __.-__ Dia.of Well Casrng
<br /> I I Domev-0i"ivate [!G,a,el Pack i i Tra.v Tyne of Casrng_,-- _ Specdicalrons
<br /> I' Pubtrc i i 011ier -1 De!Td Oei lh of(ifuu1 Seal _.__..___..w.-... .Ty7e o1 Glow._II-._
<br /> I I In rye lion ._._ Ap1nu+. 0,-6)lh I I Easlem Surface Seel L-ahrlknl t'v
<br /> Hepar Work Dcne t t Type of Pump _.- --_.-- It P ._ .___ �__. Slate V11ork Dune
<br /> Well Destructs,,, t Well D-amdlcr SeaE-ng Malanai U011 50'1 --._-- .„_--,_-_...____._—___._._
<br /> Depth h!dlenel IAelow 501
<br /> IYI'6(TI'SL PI IC Vjtmo_ NL1V INSTAL IATiO N 11. fit fwlt,ADDITION I M1,;lI (;Tl0N I 1 INo ncttuc.5vsIe ,permrllutl d priblrc sewer rs V
<br /> dvadeble wifun 700 feel,)
<br /> tnstafla[ron will serve: Revoence_.._ Comme,c,st thrr-,LL•__-_.__. __
<br /> Numbw at 1-rig units[ _.,„ Numlwr M hedrooms
<br /> Characlw of surf to a Oc"m Of 3 Icer: _ _ ....-. _ _ - Wale, iabla oepth.Y_.
<br /> SEPTIC TANK I i typel!Afq Y`..� _ ._. __.__._._-_.. CaFacdv _�v_�' No. Compartments
<br /> PKG. TREATMENT PLT.i ! d `Tulhod ut D(iisposal
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<br /> Drswnce to ne'aiu•St: Fbnctat-.n .(`'..-__-_ F4oftu rtY to_e -4•.T... -._
<br /> rl5`
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<br /> LEACHING UNE t 1 N..S Eengll,of Imes _ ,� r.._/.L'r._ 1.131
<br /> RLIER RED- --_{ t 1Astance to nearest 'Nell (%-(,-_-,FoundaU.n - 3,L' __.Property Line
<br /> SEEPAGE PITS i 1 Dept t �� __� _
<br /> _.;I' ..I. Slrn rl�_� - --t Nus„har f1
<br /> SWAPS 1 1 Drstde.e, ',•rtedlast: W1,11.j �_n Far,ndahnn :.,1�-'., - P'op-av One
<br /> DISVOSAt.PONDS t I
<br /> !Iwfehy canny[Tia(1 hove pfepalod this application and that the work will be dwir to occowance w,:h Salt Joaquin county ofthnanc�s,116114 laws,aAd
<br /> rules and rayuiatiuns of Lha Sen Joaquin Loc31 Hcatlh Dints(
<br /> Hof re owner a;l,ctasad agori['s Utanalule call'bos this to9DA.rtg "I cerlily that to the pottonnance.f the work lot which this pefaiiit is issued.1"11 not
<br /> employ any person at such rrsanttor ds to 1x uma subte,l tri wml,ma'i's tunl-r nsauo, laws of Celtic.rna”Cowfactof's havtg of sub contracting signature
<br /> ce:[i!ws the following:"I etrtgy that,n the pert[.rnran.a of the wo,k for vduch Ni,s pit rrn,l r5,sued,I shall employ fi",wns subpect to-w Lmsn's compeoLa, I
<br /> lion taws of California.-
<br /> Tht,applicant muni
<br /> call for as 1 1 rr.tl.nsl-,ti.n: Compiatu dw-ntl o„ft•var5a s'dd
<br /> ! p
<br /> Signed Dale:
<br /> T \� R DEPARTMENT USE ONLY y
<br /> Applicahon Accepted by __'M..= _--�.-__ [1e[a- /�,.,.,ti.. ..L-_.„_�_ Area, , �-��_,•�
<br /> Pit or Gioul Inspection by Dab- Fam!fnsvuchan by '� -- Date-J-j�q'*�
<br /> -^��---- �..-...-,mac`
<br /> Additional Comments: It�-_a _cr .-- —
<br /> I-t St4 40W6781 [I Loor 349,3G2i [ }i.n,,, 82371 [:: 'Tsar•. 56385 ;
<br /> ,'•-"' Applicant Return rll,cople;10: fgvaunmen'al 14caltn I•nenuVSerntes 1601 F, Hatolton Ave_ Y.L [Joe 2(Y)5, S'k., CA 5201
<br /> (, I
<br /> ET AMOUNT DUCaStt
<br /> E AMOUNT REM117ED CF� hEf Ers't3 Fir
<br /> FELArt.�...... PERMIT'No._.�_. —__
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