|
r �fy
<br /> i D
<br /> APPLICATION FOR PERMIT
<br /> SAN JOAOUIN LOCAL I-IEAi:fN DISTRICT Cory
<br /> . 1601 E. HAZE,i ON AVE,. STOCK FON, CA
<br /> r - Telephone {2031 466-6781
<br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED �
<br /> (Connolele in T riphi,ate)
<br /> Application is f}r:,ebY made to the.5ar•Ar�pCUin Local Heahv Disnicl for a r-nr,rr 10 cunzce ru C:AWI'Or instdll 11117 work heroin desCrihL'rf. This appliCdiion rs
<br /> f� maria in compliance wilh San.lu:Squir.Cnun!y Or,f+nanca rJo s7Q fur sewage or No. 1f:et?.,fur v,•1:!!;punt;,dn:f the Hui ems•.and HequtatiPns of;he San JOBgil Irl
<br /> T!''Y Local Heaf0s Uisnir-r, r
<br /> ti'y
<br /> Jol,Address
<br /> •� i Owne:'sName Address
<br /> p}
<br /> - `- - -- lnne
<br /> Contractor 6e Evli-_,CS,_v�
<br /> TYPE df VJELLlPUf54P- Na.L ]_ �_Pt one-✓,_ f'E5�
<br /> 1� �F T_ - tJE.Y WE WELL HE !ACEP,JEt'i !! LIES:RUCTInN—C,
<br /> c+ Y7t•�5P r." `
<br /> �• - PUP/,P iPJ,i'ALLA'fi^,N 3 SYS'T,A1 REPAIR 1 1 OTHER C Fr J'',,r. A .� •. �.
<br /> ' DISTANCE TO NEAREST: SEPTIC TANK
<br /> SEVER LINES DISPOSAL FLD.__ _ YRpP,J(N
<br /> FOUNDATION { L
<br /> ACRICU
<br /> __. OTHER 4YE1.1_� PITS;SUMPS
<br /> f. r INTENDEO USE TYPE OF Wf't L T PRORt.Eki AREA CONSTRUCTION .)PECIHCA11ON. - t
<br /> '; yk Cl Industrial C] Open Horom €-i Mataura - Dia. of Wolf Ear.avarian J �
<br /> l r�------ Dia. Of We
<br /> 11 Casing --- -
<br /> rf
<br /> (7 Gravel Pak --i Trat;y Do'nestic/Pr'Vatc 75pe of Casinr _. _-
<br /> O
<br /> Pnlhlic E7 Other _ _ Type of Grout
<br /> r + C OIa Depth of Grouz +cal S-
<br /> ?', �' ! I t•ri6iliorl _—, A fi rot- Ue•th I I Fasnttn Surface Sedl tn5laecd b t�_
<br /> r Repafr V✓nrgec " 7 urt,;> - `---- -��.---- -- -
<br /> y k DYPe of P /,f---,---- ILP. '- 41'ork Done
<br /> f ° "Jell Desrructie^ i-. 'Nell Oiamete7 W.,`.T__ SvmJinq Materia!{foo
<br /> ey
<br /> Der-1h x _---- FI!'er ial JBi_.lov;54'?
<br /> TYPE OF.$CTIC WOIIK: MEW INSI AIIATKIN' i i Nci';Jt+A11DU1(JN ! DE$TRtk_ TGN (
<br /> , I PJn 6apnc 54Stein;tuunined if uhlir-- J +
<br /> * Ip Sewer is
<br /> r availabit'within 206 feet.)
<br /> -, Installation wiI!serve: Residence Commolc:! Qtn:r
<br /> S
<br /> I` Number of living urrits:-._ a
<br /> NUMI)°r of bedlarlrT15 .
<br /> •: ;.,
<br /> {,; 3 Charzcter of sail to a depth o1 3 feet: ,-------- -_----._- _------- -water fable depth..--_
<br /> SEPTIC TANS: !.7 Type/Mf} No. Cornpsrtrtenls
<br /> PK(,-. TREATMENT TILT. [.I Method of Disposal
<br /> Distance t1a rt•ares?f Wo ll_-_. Founda;inn,.-___-- 'Property tine.
<br /> TTF ,y LEACHING LINE 1.i Na. & Lr.-:rgth of links __ ----- -----
<br /> Total
<br /> iartrJtf;lsi.c___ _ �.
<br /> FILTER RED IJ Uistartce to nnaresl: 'WellF t �
<br /> ouridalionP(opnrty Line
<br /> SEEPAGE PITS
<br /> SUMPS i I E}ry?,ut%ir u)r:e-ar2sC Prcperty Lim•
<br /> - —�
<br /> DISi'OS,'+.L PONDS I-1 — r'
<br /> : ,<.• ,'t; I hereby certify that I have Prepared Ibis ap ;jllir::dfh fh-s:rirtion and Shat ' vr
<br /> rules and regulations of the S.1n Inequity Lr)C>cal wk wi;1 I,e dont! , st
<br /> in accoldanre with San Joaquin cnunry ordinancesale laws, and"
<br /> a , J
<br /> + (-koR1C owne'or licensnd ail E's siynuture cttltifins 1hn fr)liownq! 'f r:r;:tify zhat S;:!•n radorrrianco of[he work for which this pormit is issued, I shalt note 3'
<br /> L
<br /> employ any person in sur t'n rTrmr as En become sublicr to vrorkn,in'S C01110ens-160n laws of Californ;a"Contractor's h,irinQ or suh-contrae[ing siflna[ura11%k
<br /> 1 t
<br /> certifies 7(5e follr,wifl," Certu [hat in the pQrfoln5arico of the work for whicf7 this permit i5 istdred,1 shall umploy persons suhinct to workman's compunsa-�
<br /> tion laws of .;ifornia 4,
<br /> w
<br /> 4F/`/. The appliCa nt tf1' t all.f r o v irr;d,/ 1!c105. :gilpluta drawrng on r9ver5f7�icityi
<br /> �' Signed X_ r•••�� . Tour,: ��"��T..(P+Y'c.�•� Dato:
<br /> v FOR DEPARTMENT USE ONLY
<br /> t _ _ `�y
<br /> Application Acreprad by _/y//1���c�: ��_L..i...t�� , 1 Liz v
<br /> '�--` �-"�.._.._ .._-. -- -.. ---� _- - 1 Area
<br /> Fit or Grout Inspection by � j - x,11/..__: li:,!.1 i1%f,a j�'/ }'in31 In Spnclion by Oate
<br /> . _yI` is
<br /> Additional Commems' .-
<br /> p 0 Stk 4666781 0 Lodi 3693621 P Manlcca Q:,-7134 El Tracy 635.6395
<br /> Applicant • Holum all er)p}cs to: Erroironmontal H,iahh Potreo!/Su-rcos 1601 E. HB-I!oel Ave., P.O. Box 2(1()9, Stk., CA,9S161
<br /> 4b
<br /> INFO "SMO UNT SUE AMg4NT 110,111 TE.0 !t(ICEIVCF]BY OAT6
<br /> CASH -^U PEKMI7'nit',
<br /> U rJ (+i
<br /> a:L .Ell 1334 li1':4„y�,
<br /> �y
<br /> Si„
<br /> L♦d.RS ,�_ ���'.Lade i�,:EIJrY:''Yuwi
<br />
|