|
t
<br />� lL��Gy a ice, •u � ,�.
<br /> I •�
<br /> APPLICATION FOR PERMIT
<br /> "^ c:
<br />.� ' SAN JOAdUIIV LOCAL HEALTH DISTRICT'
<br /> 1601 E. HAZIELTON AVE., bTOCKTON, CA
<br /> ..4 Telephone (209) 466.6781
<br /> PERMIT EXPIRES TYEAR PREM DATE ISSUED
<br /> (Complete in Ttiplilrate)
<br /> j Applreation is hereby made to the San Joaquin Local Heatth District tar a permit to constntct and
<br /> for install the work herein described.This application is
<br /> ."made a compliance with Son Joaquin See Col+nty Local
<br /> H No.549!�•sewage or No.7562 for welllp mN end the Rules sort Regu arsons of the San Jodquln
<br /> n Local Heallh District.
<br /> �
<br /> Lot site
<br /> 1 1 r PM
<br /> r 4 Job Addryas n�
<br /> 9 _,Address y ;
<br /> + Owner s Name 1 11
<br /> 9f !i
<br /> * Address r c_ h _Phone a,
<br /> License No. a r•r z { j, „
<br /> 5 Contr�clor_. ----
<br /> NEW WELL ❑ WELL REPLAC MENT ❑ DESTRUCTION ❑' t.
<br /> TYPE OF WELLIPUMP: OTHER ❑ ` s"'�iti
<br /> PUMP INSTALLATION q SYSTEM REPAIR ❑ Z ` r y,K
<br /> SEWER LINES --DISPOSAL FLD. _PP.OP, LINE p
<br /> w7ANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITSISUMPS
<br /> ,iL...., -r' •: FOUNDATION •� s' _ y:
<br /> rte,INTENDED USE ;YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.of Well Casrrrg: r i># a5
<br /> Induttaal w - c❑.41�n Bottom E]Manteca Die.at Well Excavation ry
<br /> Type of(asinq. Specdicaiions
<br /> DornoiPrwat G Gravel P kF J Tracy Typo of+riraut
<br /> y. ({Puhlle n Delia: j DePrh of Gw t Seal
<br /> 3 y
<br /> -1 In tbn Approx. Depth tl Eastern -,r duriaee Seal Installed by -�• �, ,} „�i" t;,"•` r°�.
<br /> •�9 rR H.P. State Work Dane x F,
<br /> Rel,air:ti'ark Dane v U Type of Pump.
<br /> Scali Motorist(top 50'I
<br /> Well Destruction jt C1 LVull Diameter "g
<br /> r Filler Material IBetow 50'1 — Y
<br /> — 1
<br /> JP,TYPE QF.SEPTIC WORK NEW INSTALLATIO REPAIR1AD71T!,7N I I DESTRUCTION I j.aNaltabletwihin system
<br /> i ad 200 feet.)V rtfquM1lrc et is
<br /> �,'st.��.�`�" µ + ':•r,!> .fir ._ _, Y .S. t• "1�r L 9"' #.
<br /> Instalktrori witlserve�Resdence Commerciet. Other \W_�� .t
<br /> Nuntlter of Wi untes +Number'uf bsdrwm}
<br /> Water table depth
<br /> Character of soHto•depth of 3 feet: tri
<br /> SEPTIC TANK Sr I ,�{ T ,>alMfg Ca atity
<br /> Z17 No.Compartment.': ,
<br /> 7 t a y r Method of DrtPo�et. " r ty~ t ? vx
<br /> PK3,TREATMENT.HLT Cl to [ t_
<br /> `* Dretance to nearest: Well_ Found--',;on 7r Progeny Ltne' t Tr
<br /> LEACHING I iNEr laNa 8 Length of liner lengthlsue {a
<br /> Distance
<br /> to nearosrt:' Well� Foundation n �> Property LrnO
<br /> Fif r1t"aEa
<br /> j
<br /> i4t t.,it `{ �' P. Number
<br /> �EEPACE PMTS :r�r�fk fr.K-06e th tit
<br /> 6Astanee to nearest r,Well Foundation Property Lina'_
<br /> SUMPStI 4 s r t `tt'✓k�S r -;wt- P4_y � r ,c
<br /> OISPOSAUPONDS ❑
<br /> I.hrrepy�Gflrnty that 1 have nrapated this appttcation and that 0*work'wdI he done in accordance with San Jarauin county ord noes'a�ete�laws and "Mt
<br /> I' a tolls'anQ'r�auletiartti'of ilia San soaquin•f oval JA trict
<br /> fioritesovrnu[or-licensed:agent's FlgrMtuie rsriifiei the following '1 con, that In the pnrtormance of the work for which Ihls persrrit is issuers )'t ILaq not, f{�¢ k ,x..
<br /> srnployany Person in Such manner as to become subject to workman's compensation taws of California."Contnetors hiring a sub contracbrtg srpneture {
<br /> • certi!ip ths,iptlowfng: 1 Certify that in the parlor main of t1•work for which this permit is iewed I shall employ persons subject to workmen a companaa �r
<br /> .r -,s`.Ww+x�a.y,t. Mrd"' �' _ y` '� t.
<br /> ' .
<br /> `ha`appkca putt earl fa• r ulrod Inspeaaons.Complgte drawing on reverse side ss
<br /> raw: "•r _r �S. ! - }_ Date
<br /> yy ye ,z�rfArr'.e /fir)//1�f�1 �/i��r Title
<br /> i $Ig r 3�"""�Z ..•s rc � .F r r � � `. r n�«,; i,�' ;P ',i•;i eF-.>� a�ti '4 i� +7�f , ti��' 9.
<br /> �!
<br /> FOR Dt?PAATMENTUSE IINLY �.� • per F"j„zi'r 1'1`,�-'Sv��;. � I � w��w. °�a.
<br /> • %6j7nc+Y"�' •4' .: -Dater••!AreAgF
<br /> 1pplteatlQn Accepted g.rv+. ;t r r ;ijy +��;� rtisa• er
<br /> r{ DateFinal Inspection b Date j
<br /> 4Q or-:G[ailrt Irtspectrort bYh` , , .w i.. �.s q 9.r➢r� �' rte" ,i,�, ax"5'� "� ""++e.'•Ig3r r y.
<br /> ;. +Bk�'�y `+ .�."vs�'+►.i. t 4 .d. '- # -' ""'. . '{ °�,,,, c '' • i � rift �'
<br /> .� 'A�5.;r•r�tr Ami. Sib. a a L � ,'r' +'ter .+ e,1+�,x�a
<br /> S Aridkiaaat Corrtma . 'r Manteca 823 04
<br /> e O,}ftic kAfifl6761"`t3�� 33821 C7 Tracy 8358385 r tw
<br /> i pplM7ant R-a�turrt all coglrri,to Environmental Health P+rmit/Services E.'Hazelton Ava P Q�Box 2409 Stk CA 9x2(11 qtr cr¢ 4 zy� C.
<br /> .; �.���' '��7✓'�,'k�'i'"'+-��ych.�hn.�i3.�t hsL1�RM� �.r g`L` r '. ,t .x ,.: °.'.' �L?`�'. ,., _. , r ri� �4�ti r a
<br /> WEFEE ` 7.+ ''AMOUNT REMlTTEF 'RECEIVED BY I;- f9.47E PEfiMtrtrtie.� INfil ALrtOUNT pUL a - nuv +.L C - i k aazSs�nEV.rk nu , $.c= Q x'�d t .i 4 r `t,z, .
<br /> 1N143a yi' '`"�<s �� �.�;�c1 t ., 'L -:. : - : k F�:y� s ;-'L , .i'. a�•rt���i� � !,?'
<br /> a.. Z�� r• ��-p�7t�rr'"Iw���.]Ar,�,fj`+�p�yP�llaFt""r."irk.,'.'s`;�-..�; rr � _��������-_
<br /> 'F , V: r1 t �' q )E. s {a r 'f, x1s f6 +h, i'L�"'Y •f �, -t .v
<br /> kIi�] £.
<br /> V.
<br /> D{�`�r >4�t��Y.'yv�,w�"',I•,'�{ 'lk!` ri_.f� 1 d - �a � "' il�� r ;' w
<br /> {} ♦"a':��,t r"d''�'(f 1. t. " ,. '� aR- Ik e y 4.i a 1
<br /> yg �. �3• •'rmT el f0' -. �A '3az � ,'�,� e r `.i a Y P
<br /> �.i �J6�.tfat:al4��t:Frt;f,.t,T4•'r.R,�''1'. ,r> a.. tr ^'v`. ';.a, '„* ♦t:, -4:
<br />
|