|
APPLICATION FOR PERMIT
<br /> SAN JOAQUIN LOCAL HUITH DISTRICT
<br /> 1601 E. HAZELTON AVE., STOCKTON, CA
<br /> Telephone (209)466.8781
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> (Complete in Triplicate)
<br /> Application is hereby made to the San Joaquin Local Health Distr'et for a permit to construct and/or install the work herein described.This appYeatlon is
<br /> meds in compliar►ce with San Joaquin County ordinance No.file fa sewage or No.1982 for weU/pump and tits Rube and
<br /> Local Health District. Regulations of the San Joaquin
<br /> r
<br /> Job Address� :9Q M i T t) n _� / /
<br /> .. :ihtf`LIsC-1,.�-y� Louise pal
<br /> Owrvr's Nams M,P 91 MK,V ,BREI r3r.C,(pdd,ess L� _C'LR1�_�-Tt- 1L�- Phone .43 - C/q
<br /> ooK��,��✓v' WwroR rys-r s r/
<br /> /5ontracl A�dres,,.2 _)d �O c/� License Nc. / phi O
<br /> TYPE OF WE:1/PUMP: NEW WELL 'HELL REPLACEMENT C DESTRUCTION ❑
<br /> PUMP INSTALLATION�� SYSTEM REPAIR 11 OTHER ElDISTANCE 10 NEAREST: SEPTIC TANK 0/ D "t SEWER LINES -- DISPUSAL FLD._ PROP. LINE
<br /> FOUNDATION AGRICULTURE WELL __- OTHER WELL PITS/SUMPS _
<br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavatbn � Dia. of Well Casing
<br /> m �o '•
<br /> Y'r Doestic/Private 5(Gravel Pack C Tracy Typo of Casing- _ Sr
<br /> C' Public n Other i', , rficatiors Car.-a v}-a t►
<br /> L Delo Depth of Grout Seal 70 (� N � Type of Grout
<br /> C Irrigation ---Approx. Dept - C7 Eastern Surface Seal Installed by_
<br /> Repair Work poste D Tlpe of Pump H.P. Jr State Wok Done
<br /> Well Destruction I V/ell Diameter Seating Material Itop 50.1
<br /> Depth FO*Material(Below 50') --_G RRVE�'
<br /> TYPE OF SEPTIC WOR; NEW INSTALLATION Ll REPAIR/ADDITION n DESTRUCTION I i (No septic sstem permitted H public sewer is
<br /> ,,,C1
<br /> Installation will serve. Residence— Commercial .__ Other available`within 200 feet.) "7
<br /> __- -_ - - D
<br /> Number of living units: i- Numb..( 4 M4rooms
<br /> Character of;oil to a depth of 3 feet
<br /> ^ -_----- Writer table leplh_
<br /> SLYTIC TANK Type,M' -_---_ C40city No. Com
<br /> qF'
<br /> ':NT PLf parlmmts ---
<br /> Method of Disposal
<br /> ' Urstanca to nearest. Well ._ _-_-- Foundation Pirperty Line
<br /> c..i Irv. •'.E Nn .. Length of Innes --- - ----------------- -- ------- y1
<br /> -- — --- - - --- - ---- Total lengoperte__-
<br /> r
<br /> nit iEP AFD D.stanee to neas, Well ______ _ Focndauon property Line_
<br /> 31..F. De - -"e - --
<br /> _. .-'---- Nrrrnbur
<br /> S. M Drsu..c to nearust VlLa _-- foundation Nrolxrty Lr,
<br /> L _ , -- —
<br /> I r.arur r. A I f.aprepare]this at, I. • , •nd thi,t the work will be dune in ICt.urudncu with Son )oaquwi county ordinances, state laws,end
<br /> rul.•_ _ It ens A the San.),jqutn Lorisi Iw..-t1r District
<br /> KV- MA r ct sed agent's signature artdrus rile tnkuwl(q) "I curtly thus.n the perforr :ere•u of thu work for which this pr.rnvt is issued.I shah no.
<br /> li:k my..,.son in such menne•ms to become sur,,Ct to works in's compen„ation Idws of l didOMIJ.•'Contractor's hiring or sub•conuactirtu signature
<br /> .f'. -te fo!'ow ni, "I certify that in the p ' n4oct of th•f .rum'or which this permit is rssuud.1 sh:rl untploy persons subject to workman's componsa-
<br /> ,n laws if Calrfunua"
<br /> The app6cagt u all or I requ,rbu inspwctions. '0'r:,lele draw,,,,,on reside.
<br /> n •�
<br /> Signe0
<br /> ✓ - l t '�' - \ - t Date. _
<br /> n FOR DEPO' 1ENT USE ONLY
<br /> Apo:,c in Acr`ptert b/ . / e, 7 r �- //-� 7
<br /> �� •ft. 7u Data - -- -- A.68
<br /> Pr. cr Cr Inspue,.Jn AL- Date 7 ...t,G { F..al Inspoctrun by •/ j�/ _ Dat✓' ���- A _�
<br /> ♦�JrN1vjer�G - :✓tom- -- --
<br /> 4dCrtional C'n ,rw;tt>' �-yCr-'�--'`/It4?ACS.-.-"'_.'�.�.`_t_.1.�.-..1=%��,.L. ./�C/ .t►1-✓✓l�.v_i ,
<br /> Stk 466 91 Lode 3693621 Manteca 823 7104 Tracy 835-6385
<br /> \ppl.ca.tt Heturn 0 copies to Envoonmental Health Permrt;Servlces 1601 E. Hazelton Av,i., O. box Z$A, Stk., CA 95201
<br /> FEE AMO DUE AMOUNT REMITTED CK
<br /> s
<br /> INFO CAS M NECEIVC Cr I LATE PERMIT N.-)
<br /> i -7,
<br />
|