|
»� r'�t,�'�4'*;� � !, i •`is: ^n• �:'+- _,t��.`. n.. .•,�. .. 'ei^r�.,. .v-i,-� .•.,•-t:r..ys�
<br /> f t
<br /> APPLICATION FOR PERMIT
<br /> • �. .w .
<br /> SAN JOAQUIN LOCAL I'IFALTH O157R1CT
<br /> 16x71 E. H 4ZELTON AVE., STOCKTON, CA LjGHEAL'TH SBR�� 's
<br /> Telephone IZD j COLTNfY' Im",TM D[V15ldl�l
<br /> ' PERMIT EXPIRES T YEAf. FRO, T
<br /> (Complete in Triplicate)SPECIPERMIT: i
<br /> �Y,
<br /> "„ Appkation is'#w0by made 10 the San Joe4uin Local Health Diairkl for a Ixrmit Io comtfuct andla install the work herein desuibsd•T1tla tlppCatext in '
<br /> rnadr in eon+aE.x+oe wiM San Jo.4��Court^N Ordinance No.549 tot sewsM a No.1862 for werllpump.nd the Rules Rrytrl.Sioru D!the San Jospin
<br /> Local Health
<br /> • j Job`Rdtlress• .2w City��6x-Lel Si. r :• .`
<br /> q+l l; .j4_ W Y. Phone+ ?
<br /> t ~D",-,
<br /> Name t h Address „- ,
<br /> �ti 1A3;Sf % t6a1�Lic4� t ,y�.rr1'<cS,ne� Addte�s '}a� enseNo.��3_
<br /> Gonftatta �
<br /> Z1. 4, i TYPE OF WELLIPUMP:.., NEW WELL WELL AEPLACEMEf+t [1 OESIRUCTION l]
<br /> PUMP INSTALLATION ❑" SYSTEM REPAIR ❑ OTHER D
<br /> r
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEtiYER LINES D15Pf)SAL FID.. PROP.LINE u
<br /> FOUNDATION � 5t- AGRICULTURE WELL OTHER WELL PITSlSU1diPS�_
<br /> IN7EbDED USE -: TYPE dF WELL' PROBLEM AREA CONSTRUCTION"EC1FICATIONS s ♦a
<br /> 4 Induabisi:". EJ Open Battom 1!i Manteca thi.of Wan Excavation
<br /> r M.of WN1 Cn;,v
<br /> _ .��._• SpPeirications
<br /> p Oonsgre/Prlvrt. . �G+aval fsaek ❑T
<br /> �- hey Type or Casing 1—' .
<br /> �i Public' fl O n Delta Depth of Groot Seal _ Typ.of Grouter l.Sgilt7_�
<br /> rtf 1 I 1,19
<br /> st,on.; - S_D Auprov.Depth --f I Eastern Surface Seal Instanud by Tanen:
<br /> Repel Work Oona �] Y Type d pump
<br /> 14.P.
<br /> scat.WttAc Done
<br /> r i Sea Materiel flop 30'1
<br /> I Well Qeetructlon D Wal O�wnetar T✓W G~
<br /> J i rwDepth F1W Melrwd 19610w WI
<br /> �-' n mfled N bbC tlewa►5�•_:
<br /> ,{ TYPE OF SEPTIC WORK_. NEW INSTALLATION I I REPAIRIADDtTION I 1 AESTkUCT10N i I INr, bla j&.in per fur _
<br /> � 71 ", - avatlattls whN•kt 2A0 1eet.1
<br /> r 'h Inuaare+on wAl serve Reaidencs Corm fcW Other a v
<br /> 1
<br /> Nurnbe►of>{er,+Il write: Number d bedrooms—
<br /> Character d sol!d a depth of 7 fee Wafer table depth s
<br /> Ii SEPTIC TANK"� D. TypelMft Capacity No.Compsrorrnts.
<br /> r 301(C.TREATMENT PLT D r" ItAethod of DePaal.
<br /> " r '
<br /> Dig—
<br /> No.
<br /> nearest: Wen Foundation Property Line ! u
<br /> LEACHING UNE ❑,INo.8 Length%Snas TcW kwwh/sire ,r
<br /> i FILTER 8EO'' Well Fpundation Property Line Y,
<br /> ❑':Oista,w sO rawest
<br /> x _� SEEPAGE PITS 1 1 Depth Sit. Nomba Cl r v
<br /> SUMPS L•1 Distance to nearest: Wel Foundation Property Lina
<br /> 1 DISPOSAL PONDS D`"
<br /> r. c:• I fsntby earthy Vil I have prepared tfwe appb6catlon end that the work will be dorm in accordance with San Joewirt amr-Y adiM"c4*nate Isw%andt<
<br /> and rrytdariom of the San J064uin Local Heetrh D3erict.
<br /> owner or licensed agwtt's siWwtun artiFmA rte fOeowing:"l mrrify that in rhe purlorrw,ca of tls work!a w►,ich 11tk permit ie laterad.1�FteN trot:;
<br /> a such rnptnr as to becorna nrbO&ro WO&MIen'a eompaneation Iawa d CakMntia COnirACUeg hiring«act.oontreCtinp S%Fwk re„
<br /> etnptoe'any taaraon- to workman's oompsrna•.w
<br /> the lo6ow4np:"1 oerrifY that in the peAomunu of the work 1«MA+ict+this permit b isawd.1 shat employ pervonr sublsct _
<br /> r�r tion Jews of California."+.,_.
<br /> f _ tite•applicant nwst Canf«all requited+tsPKtions. Complete draw nq an reverse aids. •. _, r.�
<br /> Title: F i�!'�✓ pats: y.
<br /> 4 S*-d
<br /> FOR PARTMENT USE ONLY s t
<br /> Ana 4.3_
<br /> ApPrrc+tron'r�ca.nee by
<br /> j Pit or GrOtrtJinavat tion by r!./cfl}."'�P Date/j/ 9 reed Inspection by r f
<br /> ddkk �.L/.C. ,�� �1�.! .(`/t./►..rr�1 !�I'4llr+--/rte/ "' .. . . .. .. •�',
<br /> Arel COnvmn4:
<br /> F - D Stk:1110-8761.. - ❑.Lodi 383.3821 ' D Men B23.7101 D T104 636-E3B5 .' :'.. : .� -- ._i ,,'•
<br /> Apyfkant•Rututn rll popiea ta:Envirorunetual Heshh Pr-1.0Sarvicss IMI E.Halation Ave.,P.O.amt a=,Stc..CA 96201
<br /> w - .�•�—••y -
<br /> ti AMOUNT MA AMOUNT hrlrAiTTEO CASH F11c,vRD eY -OAT[• rEAWT'No.
<br /> 'z
<br /> i op 00
<br /> �7055C
<br /> S, '. .._ -... ` ..L4�.i ..•.�.....1:,..•.l,'w (:vr. .y'�.2:Y.-.%.�CrG�:++w•r....r.+.lr...,,:....,r•.." .+...«.. .
<br /> _ .a.-�..a5:�.^�ufiF�!t."7iw�:.r3r.:'ir.r...V. ....�r.�.".r.: •f�. e'• ��µ# '.:.
<br /> `; �• 7. �. 1 .r.� _ _ .1 '� +i ,i ,5' t 7. 'C y I c �� h�:
<br />
|