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4 ' APPLICATION FOR P£RMIT
<br /> JOAQUIN LOCAL.HEALTH DISTRICT r"Si �"(�
<br /> 1601 E. HAZELTON AVE., STOCKTON. CA l'
<br /> Telephone (209).466.67816/x`.. r,:z•wy
<br /> ,
<br /> one A '
<br /> r� r PERMIT EXPIRES ! YEAR FROM DATE ISSUED. 7.; t �
<br /> (Complete In Triplicate)
<br /> fir ' ,a A fppllCattort is here°try made to the San Joaquin Local Health District far a C9tinit ro Eonstfutt and/M fnsfsp t work s
<br /> f * made In eurnpBance with San Joaquin County Ordinance No.549 for sews or N19!12 fa weWmD a
<br /> lit
<br /> t Loraf Moaith District, Y c ,.•� 9° o. t�RWas �r err
<br /> ryob Address �3z .! h.� -/of
<br /> 10 City�✓! Lot 5i:er ' =.�Sr Pi1A'�r" N
<br /> 4: rid�fr "
<br /> ;,fir► �,�. ' Dual' esi'� ren 9a ,�
<br /> 5{5�,YY Owner')Name AddrPtirtile
<br /> * mow +„ i.odf'. t•F ';.. `aJ fa> ''•'"r ",�!! j( 0o': ':_
<br /> titer ,F Contrecta �,(� . Address .55'�� ��t[..Licettse No. Ao/ Phcne _sV/p
<br /> TYPE OF WELL/PUMP:y -:F,r' NEW WELLWELL REPLACEMENT.0 DESTRUCTION CJ
<br /> , ��-
<br /> f ' PUMP iNSTALLATlON C3 f' ` -
<br /> p SYSTEM REPAIR � t, OTMER'O'.
<br /> F j,AA DISTANCE TO NEAREST �SEPTrC TANK �Ol� �:` 'SEVIIER LINES '"' DISPOSAL FLD.&d PRDP LINE
<br /> f f �y�!F V' �"FOUNDATION _' AGRICULTURE WELL 0T14ER WELL " '� PITS/SUMPS,
<br /> Y °� INTENDED USE.'a.° '•.,TYPE OF WELL PROSLFM AREA CONSTRUCTION SPECIFICATIONS `' ", ' �' �•
<br /> a aC3 ndusttiai,pry ° O Open Bottom a. G Manteca Dia,of Wjfl Excavation Dta of Wail Cesingt44
<br /> ,. � +� yDomesticli'rivate t`f�;Grave!Pack` e t�Traty - mType of Casino SCecHications' y, ,4 x j
<br /> t 4 P ��Publ a "}i ;; €� �:.� O Other ,if �. u Deka Depth of Grout Se �� 4f �'�•.:Tl,pe of =
<br /> rrfl lrngatron �Approx. Depth 11 Eastern ' t:: Surface Seal Instal
<br /> .t , Repair Work 064,,;Cs; ,Type of.Purrip _ M.P. Stats Walt
<br /> Destruction CI
<br /> Well Diamemr " Sealing Material IrDA 50 i ' L' s' r
<br /> Depth .'t.►� S'r' ,r 4" Fihm'l Matedat[Below SO')
<br /> TYPE OF SEPTIC,WORKC NEW INSTALLATION❑ REPAIR/ADDITION U DESTRUCTION i� (No septic system permitted if public sewer
<br /> available within 10D feel.)
<br /> 4 ,irt 'Inistallatiori will serve `Reatden; �'. Commercial_ Other
<br /> j � Number of WN unrt/:-' :F Number.4f bedioornS ?': ." :� ':
<br /> I,!Cha�actai of:~ to as depth of 3•eet 's Water tabh tiept}r ss � ' r
<br /> ,r` aRsY SFf°;it'-TANK CTI r TypelMrg Caper+ty ' `No.'CerterLrterw"
<br /> h { PKG iT!4EA' P!T 0
<br /> Method Of DupoOaf
<br /> %r ° + r
<br /> � Distance to nearest V.
<br /> Well foundation Property Line ,, r
<br /> k, y
<br /> .;q"T�°} �y, �'��e �• . ,� st:I�:•8 x �, r..�n'. �y-,y
<br /> t k'•' LEACFIiNG LYtI[ `' Gro C} No.;&Langttl Of Imes' 4 ••" ° ' ' Total ter+gtti/stze �
<br /> FILTER.$ED y y y ❑ Distance to nearest: Well Foundation Property Line w "4421 .p: X
<br /> P.
<br /> jil
<br /> { u'C 3 c " �? "f r"[ h; �s Y.. '�t.:'. d e r
<br /> .SEEPAOtPITS, or�0] tDepth _ 'Size Nvmher
<br /> y r '
<br /> ."Sumps, Distance to nearest: : Welt Foundation Property Line '' Ka Y
<br /> 7! a} r bISPOSAL°PONDS C3
<br /> *� 1 hereby
<br /> .cenffy thX f have prepared this application and.%at the work will be done in accordance withSriJoequiri coumy ordinance4;state law);and `
<br /> rules;and repuktiort6 tit the 5sa Joaqu!n Lo a(Health.District.
<br /> s ;Hun%* .;r or ridinsed epert'a rlgnaturo a�Hies ctrl fotlowing:^r certify that in the performance of'the work fm.which this.perni t is Isaued;�l than not
<br /> titnptoy any.peraon in such rMoner as io becomc sub}ect to workman's compensation taws of Canfornia:'Contractors hi or,su ra
<br /> hiring bcarttrecthtp Via!
<br /> tF y terrifies the following 'I citarlty that in the performance of the work for which this permit is issued.I shalt employ persona subject to wt rkman s compere-:. I
<br /> ' .�
<br /> nor
<br /> of Cofifomta
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<br /> ;�:"A TIw appktan'. scall tor}ei! it tkns. C mptete arawing oda,
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<br /> 5rpned � �.Srf� T'r9a �.;�c.•4.�,� ria TDate
<br /> FOR DEPARTMENT E ONLY '.� 1►? � �f � "r'�A� � ��
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<br /> x #y iirgr iG� i' as as 9 : J�t��IL• ;01
<br /> T Application A cceptttd try. Date
<br /> w .�A °!i_"Wit•Nr.,'�'.p G I'
<br /> }, wFPrta Groutin to, ���i =� 9 9:11 r r�i` d ' fx r
<br /> sped 4Y �:. :pate Fina Insptxnon!;y
<br /> Add4kW ►C.omrrorm ��`j•``` _4' f// � ' ` , �5 s 3 -"' xy i 4 x r
<br /> € E:Stkv 4066781 " :I fl,Lodi;31Li 3621 v'Mknteca 823.7104 O.Tret.Y 835.6385
<br /> k as Apprrcarm Return ae coptaa to Environmertel Heahh f'emtit`Serv"A 1801E Hareiton Ave.' P.OBox 20AF° Stk ,Cepgt 9yZQti a q'
<br /> �,+� '�•, �YX 1 -a S+�s �w_.� :. '��_...a �� '� � ;>� .i,. ' 'a'- 'a_� -•�' }�. ._:4� � . � 9�� ��'��` � a;i'aec' �.
<br /> F� }� -1Nf0 At9tDUNTDUE'a .#':iMOL'NTREM+TIED' SH ,RECErvEDBY' .-DATE,..)t _ PFRMtT'ieo ��'}`�
<br /> t P. 'Al
<br /> AMOUNT
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