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<br /> APPLICATTON FOR PERMIT s"
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<br /> SAN JOAQUII4! LOCAL:`HEAI.TH.DISTRICT...
<br /> 1601 E, HAZEL T ON AVE., STOCKTOiV CA t
<br /> Telephone 12091 466-6781--
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<br /> 66.6781! k p rye i.
<br /> PERMIT EXPIRES 1-Y'EAR FROM DATE ISSUED
<br /> i:,ompfete,in Triplicate r l � rr.�.7s 1s pP eal4fon Ts'j-, c
<br /> Appbeauon is Fiersby made to the Sen 1oa;uln Local Health Drsirlct for a permr[.to construct and/o install the work herein dram
<br /> A i% ,aitadti in Compliance with`San Joaquin'Counry Ordinance No:549 for sews u or No 18621or welllpurrrp and the Rules and Regillatiogn!of[wb Sartoaqurn" tf'
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<br /> s= R�. r:• Locat Hea![hyDisit3C!r -1'�I)u t,. � -- 1 �r x5 r 7k rl r�+��YJ,�rI ,-�•T��3lr��l���'s*�'�?M'}["��� r+`;��
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<br /> WELt REPLACEMENT ❑ pESTRUCTION�C3 bt s '
<br /> TYPE,OFW MP it FtMrieNEWWELL ❑, r }sca. S F
<br /> fir; fes .� rS al ti : MP INSTALLATION Q SYSTEM REPAIR ❑ �'+�A r OTHER
<br /> t E Sr ". ; �tytral 'i^:f Ywr• r [ f J# ;DISPOSA:i
<br /> a.r D1 1`ANCE:SO NEAR ST r SEP NK- �E1fti_R LfNE51 � IN
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<br /> H WE[Lr r�E PITS15l1MP5; 1 ,
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<br /> 1 >n2k1NTENDEDIjSE t,'TYPE.OF'WELL P.,bBiNAfiEAiCONSTR SPECIFICAT10�N5 } i1h'xir � j tT`t°� Irc-
<br /> r —��� Wall Cas�ng� +
<br /> rad„ p Ir 'tnaln 7MJy � ; C]Open Bottom Manteca t of.We11 ErcavatFGit 7�r
<br /> .Frpw r sa of,Casing p Spact flcation
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<br /> $ r G1 Dortest(c}Prlvete �❑ Gra%ml Pack 4h + p Tr cY t Type of Grout
<br /> '('I ' f7 Orher Delta D p 5eal:` J
<br /> Pubbc
<br /> � � I Hiipatlon t 'xA °else ; r w Depth I I Eastwn Surface;Seul Insta al, }ars al F�rd }.{1,h r;
<br /> State
<br /> `, ' Repair Work Oane Yne of PUMP..
<br /> a Soal n -INatenal trop r-0 1 �� z
<br /> ,rut Well-Desi
<br /> r.' 4fifi4""$rwts^ Fiiler`M Below 50'1 a
<br /> -',' < x' r•.-r=elax e'r - ..... .ti:.hT p
<br /> ggTYPE OF^SEPTIC'WORK y�NE IV•INSTALLATION I, ic SyslMn Pat
<br /> REPAi A Df TI ��tDESTRU SON l,l!`�Narl bD wllh nr20r leettly 't �� r"h
<br /> ,(4A °'�;$} k -5l'sk:u"r,,�§ f =•'c +�S..S`: i t �` 5, , '1 tsj� 1f4:�"i '4 x.,r�1ytf1�'i:�}.y'`sry- �F Y .
<br /> li'.'l�'�M'�'l..9 _rr y 5 F�-r y4 b Y IJ S �r'= p�
<br /> nstallatlon will serve�R encs d �ommercia! Other �h + , �k }Pk),� c/k"+n;isp�F' ' 1 �•ry1
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<br /> a Number of Uedrao It Y1 e��m 4 r ur hfaF ifn s ro.^
<br /> '�tJurdber of liwrtg,unts `
<br /> s ;•S.v" -ti rkft�rxF. �i-ws�1.t»roirKz`t�YWater tab�E�Ogth�
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<br /> ,nara'ier o!waif Io a depth o}3 fest sr-� —J—'rE
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<br /> SEPTIC TANK + a yPe ^L Lr{ *fY?h 1' it nY,Me11jOd Of OItPOaal F .. C r ..!:i y 9trs .; 'yta
<br /> x r�(uTREJITMENT`PL`T Q p• ..SAw�' s tk r :.,G , try. � r;l b iir5 . r�raj y�rt; j ., elyk
<br /> s . ,r r ff.�uWK y? Obw.
<br /> �pist�nce t"o,nearest 'Well' ! n Foundation i t sProQertJlCins
<br /> �n'�:s� d ti3}'yri"r hs�5�`r; kr; '4 +,�r�'`?tJl=!y'g1�3�-vii_ I b7,t} J`���`�`e '�Jxi1'�- u"•Llfr� r� � � ��
<br /> «N-.n la . :'Pi-l- .4 e$ t neo-LE/ CF{NG'L1NENo')fi Length ofi -t t sWxlsdylc lonporty l.l }„FILTER#Bt2Ulc Q Distance to,:neareat d ,r ar $ r. �'krJnu ¢wk+li r5ia€ a.
<br /> qq x & An
<br /> IV k h 1 ' i "�Z r $ir -. rn A t 7' �' Nufrit»r r i►3�'a&r ii 4 [Fa�+M
<br /> SEFPAGE+PJTS � s l 1 5 th -- stt 31T1 y# 14t`Ttx l°
<br /> SCJI�JIPSy`� 'r b}A r�Uisnce to nearest F -Wall' kr'.y�Foundii on Proper<y Llnei c.a a�lr�gTf°.l@ ��.
<br /> c7:.Lr..V4',k1_ "i� x ,..SI ?+.t,.rn•', +� ��f;' "3 '.`+;t .,e:..r�" �iJ.eA..rl-:'f+ti'.- ' t! xA �1M! r {Jr,�'1Y-"�fi1�.fi _Yr!j'�"y'�� , ,�1.
<br /> DIPOSAL'PONdS
<br />{ "i? 11 heieby;;"certify that I have,prepared this appticatiori end tha[the work will be done in accordance with San Joarluln county ordlnsru es state Iowa rand # t
<br /> r "t rul$a and"regulations of the loaquin,LocaI Healih Districi i s•„ t Y F; L��{�? '-L
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<br /> oma'owner,or licensed agent's irAnat�ure':tanitles the lollowing "I`certity that in th,t,porforrnanee.al,tha work`tor vrAtieh this permit raxwed:,l stu}!not
<br /> s # 'employpny,pereo'n in such rtiartnEr.as to became subject to workman's,compensation lawa'of Culilornla ;Con:racto�s hiring orsutr,brk" cl(rsy srpruturo '
<br /> jeertiflea tha,foGowin t eartif}r,thei In the per[ormance a!the work(or:whreh thie'perrt it is Iss JeC I s!all employ persona sublect t0 workmaW+a wmpensa 7 FIs
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<br /> w� on rev rse
<br /> 1f'S Theapplrean ti 8 forWoar,1�ompele.drawin-g�
<br /> , :4 y' AX..t};5n"�^ 5L-Dale
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<br /> 'i y •..t t J t +YyC�i/ p i1 r -..� FOR DEPARTMENT-USE-ONLY H 1 tiS1 tEr 7f { r 'rig11i r ._..i %li ' �y �F
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<br /> Accepted.bY�'
<br /> I 3h '[41 L [ave{"x J�'. � i{r�S'Td.t`h,ir}� .,"'�d,e mw : ,� 2".>i ri r s Y t- Dale
<br /> t �Prt of..Grout-rtspectFOn by Date final InspectlOn b
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<br /> h Adddronal Comments:
<br /> Q Stk 468 8781 Q Lodl.A3l3621 11,1 lQ ayt
<br /> ni cap 823 7104 ❑;7rety ,8358385 ,pi ul 4 rf. a x r t; r A z, r�r a A r a r+,r
<br /> 'may Applicant 1Rai: atl copba'to Erwkconinertta!Health PetmttlSerVi4asrt661 E`Hazelton Avot 3 P O Box 2009;5tk +CA L96Z61 r r
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<br /> �,yi"{x>�✓ i.:,�� "f l t+a`r�ju f.ksu �'M ' i `x RECEIVED BYCK 8. - ';OAfE c 'PERMRNO
<br /> FEE; AMOUNT DUE,
<br /> AMOUNT REMITTED CAS}! r' - - I KI,� -r
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