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<br /> 'APPLICATION FOR PERMIT
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<br /> SAN.JOAGUINri66AL.HEAL*m'oiSTRICT s.
<br /> 1601E HAZE'TON AVE STOCKTON, CA a
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<br /> PERMITf EXP IFifSw1 YE,11R3I=ROM GATE ISSUED
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<br /> u"+Application is hsreby,made to:Ne San Joaquin Lotal Heahh u4trict, Oro parmit.to construct andloY lnsieR tfta work Fteraii ri a tcl r s am Ori
<br /> -'etads in eornoanee with'San'Joaquin County Ordinance.No 549 for sewage or No 1862 far welt/pump and the Rules and ReQGkHitirilt bTrthd 5ari�foegt�irt`',
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<br /> Oars Nartie�'�a �L' ddrass 76_4 � Phone }' ' ��t>„�� .
<br /> C njiettx' �" fi Address r �v t Icensc No %�S
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<br /> +y 4.TYPE OF WELL/PUMP`;: NEW'WELL U WELL REPLACEMENT.0 < DESTRUCTIO ❑ va t� �it k yAw �� u hI�
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<br /> PUMP.INSTALLATION ❑ i SYSTEM REPAIR ❑_:' OTHER rQ+";^
<br /> CSJ r,DISTANCE TO NEAREST SEPTIC TANK STyVER LINE5`: ;DISPOSAL'FLD PROP LINE ":et A '
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<br /> FOUND�T nN'_� AGRICULTUfiE WELL'_ OTHER WELL ' PITS75UMPS t ll� i4uy;
<br /> I �kNTEfVDI`b l�SEN r "' TYPE Crlj WFtL� ri PROBLEM AREA SpC4F1STRUCTIONS dECIrldATIONS
<br /> tixCYlindustr4l?v"3 "' L7 bpeit- ro ❑Mantocd Dia of Well Ex
<br /> ocavation Ola o}Walt Callrfg!'
<br /> ,{ mestrelPrivate ; : ❑ Gravel rack' ❑ racy,T
<br /> .Type of-Casing i 7 ; Specr
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<br /> Public 7�i + SS” ❑OtCvlr ❑'Della s e r rDe t}1 of Grout$C81 } -`^ a kType of Grout an u' ✓ ytiq
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<br /> f lrngatioh��[� Approx Depth t�-Eastern + ltxSurface Seal installed by
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<br /> State Wont Donzear r t,,' .+r5rN 3f di t epair IlYork bona ❑t 7y�"�ot Pump •� f '��'§ H P�,,,,, 'i�' • •• t .� 1 l x� r� '��
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<br /> y11i�e11`.Destr•.n.tioh� ❑ r Wap Dtemateri,+' Deal Nb�leriaT{top 50 I 7 a, `" • r �� r r
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<br /> TYPE OF,SEPTIGWOPK NEW INSTALLATION 0 REPAIR IADDITION -f DESTRUCTION(D (Noseptic�system glarmetted rf-pubficseweCis ui
<br /> aY"E" , a_ I s y • * r s available within 200 tees; z Ar.4, i .yam 1i {
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<br /> Instetlation witl nerve Rtrsrc nes� Comrnerc{al Other ' V
<br /> timber'of +tb
<br /> � t�ii•.. `T;. '>7; t .��d,. 31!' ' '} 'Weiei'teble+sal�aAih' t r�Q� �. "'rf.,� f,..rx �`r'r
<br /> 1„aracte'of soil tp a':Jdeptft ot;3 feat � F;!
<br /> SP'„ECjyA..yF� K�,'+ � pit a�r�5y5�t �y Y s+,'Sfs,!r�'!rrs"s,Ytfi•S..5'�,tfi�F ki-si apac
<br /> j TRE4MENTs� ity r .3!t, <II��lo"erlrfir hc:o'Joi dr m,{9op!aDr-tr'ianpenaifstKa,a,l,s
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<br /> �I�F���>'��'i`43'„'r �x � ',}t't J s.�oY � �' #,�i s r"r�+ w ���+� ki�,rl'fi'rr+ �S e�tt°•�l'j�,'4? �" °r�,
<br /> t .' "i.{,r, � y�rpistaneato.nearest + Wap .Foundation Prope�rLinsS..._, z c �° _
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<br /> EACH ao[ No b'I•Anptft of Iinea " YJ ° 'Total lengthlsi:a r 4
<br /> + `FILER EQsr . nom t�Dl!nee to nearestw WeE!` Fotrndatlon- ��' Property
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<br /> PITS y LY Depth,- Sire ' kumber,
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<br /> 14� Distaixato rtesrest .x Wall Foundailon }i Property Lm�re r
<br /> _ 'c".. ,.�„ .'n' t + d,' f ,7,. :,µt +bra rt t s,• �£.'.x,ix �a�. r ;'r 'iJ}:b n ' >?5u t ...��if i't4 .�ti �4t3 � iL'r/� g r r
<br /> DI�`POSAL'`'PONQS '. {7 -a� ..,-
<br /> tl l;fieieby certify Ihst l have oepered,this appiicetion end that;the work will tWddne,n accordance Wlth San JosgditiaWnry ordinances`state 4ws end, f'
<br /> + ,rsileaandregutatfons:of;U+e':San?Josquiri"Local,HtialthDistrict:a: ,
<br /> aHtJi++a owner ttx'Uese»ed bgent's`siynaturo certifies the follawinq l 1 certify that in'ths'peitormanca of ilia worktir h;this Is Swed i sftsl!nota
<br /> aniployw*-peacn in such menner.easo liecome'si{b)ect to'workman t compensation laws of-Caltfomlti. Centra`ter'a hiring onsu'at ontncting sipnaiuteJ�F ' Z
<br /> cm"M Ing'fClptNfn)"'I`eair-W giixt in&performance of if6 woililnt(6f which thls peirnit Is issiJad t shafl employ¢s�adns sublect to workman s eomparua rY�M'71
<br /> tiOn4te1V!Of CafitOfnla r i!}K h+fie lids d t P �j r )a 3J t A rfi',g.1 s ?if nb c€ t } yfk #}r
<br /> applicant mutt caul far ed 3 3uons -Comptetr drawn ori ravero sidt+ i „ 1 i 't r ' s -;n r� �} w 1
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<br /> �.+���,�sffp}yr s ra a )Y- `p FOR DEPAfiTMENT USE ONLY;
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<br /> Appllratfon Acsceptyyed by�r t __�::`Date
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<br /> Plilor Grout nspection by Deter Fina!Inspecutirt by, Detee?r�
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<br /> �Appficant�Retum'ail Copies to Environmarttel'Heelth Perrot/Servkes 11301 E Hazelton Ave P O Bout 2008 r5tit CA 16201 i b r r=�i°r r{�r1,; q r
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<br /> �It3 a:HE�a 'siiAMDUN7 DUE° �AMDUlIT.AEMRTFD r �+' Iy 'i' RECEYVEO BV1 z? DATE PERMR NO +
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