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<br /> �Y APPLICATION FOR PERMIT — "
<br /> x SAN JOAQUIN LOCAL HEALTH DISTRICT Q i
<br /> 1✓ 1541 E. HAZEL T ON AVE., S i OCKTON, CA
<br /> — Tele-hone (209) 466-6781
<br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED
<br /> (Complete in Ttiplicate)
<br /> � ry
<br /> Application is hereby made to the San Joaquin Local heaun 3i^tncl for a ponnit to construct an:lor install I've work herein dost ribed This appbcation c
<br /> mads in.:orrlplianCe with San Joaquin County OrdinanceNo.549 for sewagf•or No. 1962!or welllpump and the Rules and Regulatic:rtr•r the 5at#Joaquir[
<br /> Local Health District. rte, _ �- n tt�lt/`� C� �[, C� _
<br /> JDb Address L r�In►L� � 61.E 1f�.� Cir.�rLY�3�� � Let Sire! 2•� s6PN!
<br /> Owner's harry A - s �7 ss �1_ L��t r►1 �� _ - Pno,
<br /> Contractor's Name _ _—^''��� License 140, ` -_ Phone 7
<br /> TYPE OF;WELL/PUMP_ NEW WELL WELL REPLACEMENT DESTRUCTION O
<br /> PUMP INF:TALLATIGN SYSTEM REPAIR _. OTHEI i
<br /> DISTANCE TO NEARES,: SEPTIC TANK _ SEWER LINES _ Di5POSAL rLD. PROP LIVE
<br /> _ FOUNDA110N _.--- AGRICULTURE WELL ,-- OTHER WE:.L PITS.SUMPS
<br /> INTENDED USE TYPE rr WELL PP03LENIAREA CONSTRUCTION SPECIFICATICNS d
<br /> Ittdustrial - _ Ope r Bottom �Mant Ica Diaof Well Ercevation .�f t— ___ Dia. of W01 Casing
<br /> DomesticlYrivste Gravel Pack ':_ T:acv T5'pe of Caring_. ;j fy L _-_ SpoCifical:n.�s •�
<br /> Public E Other _: De7:a Depth of Grout Seal -a.5 ;`c of Grcut..:,�..._ K
<br /> Irripetion --Approx. Depth •. Eastern Sarface See'
<br /> Repair Work Done Type of Pumo —�� H.P. _ �.-_- State VVo?l: Done.
<br /> Wel Lestrucuor _ Watt Diameter — -_— Sealing f.laicr,al (:op 50 -.-.._-.-._---_—
<br /> Depth --— F;11er %Ia:erral,Below 5.7') -----------
<br /> r TYPE OF SEPTIC VIORK: NEW INSTALLATION :-- FIEPAIRjADDITID.N DESTRUCT:4N . 'ND sr uc I�
<br /> p ;ystc'm perm,ned rf public sewer is
<br /> ta1a,loble N thin 200 1ere l.f
<br /> i +s:
<br /> Installatic•n will serve: Re•.rderce.-- CcmmerC.al-- Other
<br /> Number of living units:_— Nr rnbtt cl bedrpoms
<br /> Character of soil toad rt,:',^f 3 leer: ------------------------- - .-._..- ----._Water (able det`rh-------
<br /> SEPTIC TANK Typt;flfg _�- - Capdcity ----
<br /> - - No. Companments
<br /> PKG. TREATMENT PL+ :: Method of Disposal -
<br /> Di:;ance ro rwwestVvea . - Founoabon Pr opery Line
<br /> LEACHING LIEF No. 8 Length of tines _ -- --_ _- _ To?d)
<br /> FILTER F.E11 Distance to nearest, Wel!..- -.- Fourie-,c.n _ _ rlrDaerly tine
<br /> t.
<br /> SEEPAGE PITS Oeplh Size_- -. -. _,. -. -.._- _-_.._ tiuribei
<br /> SUMPS D,stanre is near-i „,_?I Founaairo,n Prooary Line
<br /> DISPOSAL PONDS
<br /> - c
<br /> I hereby certify that I have prepared!his app6n Lai.cr dnn?hat Ihp ;�n`, e-I DW cIone , tcc r,rr;incc wor,San Joaou'r,coo-ity ]rdirances, State laws, and .
<br /> rules and reg Ul97iOns 9! :he Ssn JCao Gir: Local HHdI'h I),it••[i
<br /> R
<br /> Home DwrTe. Jr 5censed agent's sionaiwe certlbe5 the f:rr%Lwrng I L-11 y !!;al +n Ir.e L•.l+1Cme�Ce of:ht, :.rirk fpr whish this pe:mit c.i&$ueJ, 1 shell not
<br /> employ any person in such manner es to becorne 5,:arec[to v:urL,n,-r.'s c^'r;x nye:uln Id wro of Caldorn,a-"Convac±m-s hiring or sub contracting sigraiure �••
<br /> ceilifres the following:"I certify that in:hC perlorrtance of The.vnrk f;r r.h=Cn:h,b EW:rnd t_.. Sued,t shall er,pluy,wisrns sub2ccl to workman'S cLmpensa•
<br /> lion iaws of Gali!orn,b
<br /> The applicant ML51 W. (Jr altt Ur,ed irxspections. Cunrple!�draw,ng on Teves,: s,�e
<br /> 51g,,d XS- vim- - 5� '�� - T:I,. �lin� C/Z _ .D�te L .a3 -6"1
<br /> FOR DEPAR7MEjrLT USE ONLY
<br /> Apples ai,on Ac.L,:xe-c nY
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<br /> ?i: or Grout ,ns;,Pcuc:, hY --._T -_._ _ ._-,.- Go7c Dara
<br /> ACd-icnal Cnrnn-nit
<br /> Sa< 4blj-o"721 - L:)dr 369-K21• en-¢d E-3 715: T,c,v K35 r,:Z5 ----
<br /> App?;cent - Return all co;)*s 10. Si;i F f'a:^iter,A;� a Q Pu. `tiiCr=J, Sn ,A 95701
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