|
i try,
<br /> APPLICATION FOR PERMIT
<br /> ms's 1"a,,tE
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> 1601 E- 1-IA-E'TON AVE STOCKTON, CA
<br /> Y Telephone (209)466.6791
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> (Cornplete in Triplicate'
<br /> Apolication is herehy marl,.to the San Junr.uin r,neal HaaYli o,stlic,for a portra in ronctnrci andror sestal'thry wgrk herein described.This application IS
<br /> made in toms 1irnce with San Joaquin Coway C-ri!.nana.e.`:o.5-19 for se-)qr.o+No,t8f?for wcit/purnp and the Rules arse Regulations of the San Joaquin
<br /> .. - Local rH�mlth D:S!r!:;r,
<br /> . . Joh AAdress -f'� r .:.Irl` J_t�,.... _.1'`. (::n•1 ;.k-sr...�`Cj%yK Lo:Sire--_,.•S�^L.YI,�-_-' PM. -'—
<br /> .. - .' 4 .•:L + ,,_ ... .. ..r L I
<br /> w Owner's Name LLt_s'.�.tt. Ldd,ess ---
<br /> #n
<br /> r Contractor's':amcr -. "lr.t. s Licrrsc hip f_] •r{ _ _ phone _.���_�'_L�
<br /> _ TYPE OF WCLLIPUMP: NEW VJFLL ' - WELL REPLr.CEMENT ... DESTRUCTION L-
<br /> '' ,. --Y---��..-...-..-.-�-•_ PUh?p INSTALLATION SYSTEM P.EPAIR '. OTHER i -
<br /> - DISTANCE TO NEAREST: SEPTIC TANK ,_-_..�.__-..--_ SEV+EH LINES -.-.___._ DISPOSAL FLO..-.,-__- PROP. LINE -
<br /> ...- FOt;NL7ATION ,.._.,-_-. AGRtCULTUQE WELL OTHER VJELL_..__u_._ P1TS:SUMPS
<br /> I'vTEt:DED USE' _TYPE OF WELL PROBLEu.'IAEA CO ISTRUCVON SPECIr'tCA510N5
<br /> 4�, Ci Industrial ..m.._--_ Open Bn[!rms Man!ec,- O t.of 4Veli Erravdtion _r ___; Dia-of Well Caning
<br /> 'f: DOmeSi!C/Private Grawnl Pack TraCY Tyr,pt ravnU„ 5aecsfiCations
<br /> . rJ Public. - Other Delta Driuh n:C-00 Sea -_._,,,�-._._-..-_._ TYoe of r.rout--
<br /> :.' Iriigaticn - _._-.Apotox.Delith Easte-n Sur'' r.Seal In att.dhv_--�.
<br /> .-. ,Repair Work Done _'i.: Ty.tc os Pun'p _ "f._._...,...- -- ------- S!atp Work Dt.te ----------�� �t
<br /> l
<br /> Wert Destruction Well Diane er -._,._-... Snaking M41:,,..1:Iron 50's --
<br /> Depth...- _.-.. F•Ver laln•inr 180'ow STI
<br /> TYPE OF SEPTIC WORK: NEW[.. STALLATIO.14 ,PEPAIE,rADDITIOtJ DESIRUCT!O.IN 04o septic 3vstem permitted ii public sewer is
<br /> available within 200 teer.t
<br /> fisstanat!cn will R.me: Residence_. .. Comm7weia: Other _-,-
<br /> Number or liviry uritis:-_-L_ Number of bedrploms.--'_'#_�-
<br /> Characirr J!sora[o a depth of 3 fee[!(..�,",. .IZS'o'�",.�'O•��>_.T-..,-'ia�Ll_;t.�._•�jtJ ___Water!snip depth
<br /> SEPTIC TANK -_.1� y .1 �
<br /> TypelMFg _ Cc�n tittiLtr______.._ Capacst No.Comrerment5
<br /> e PKG.TREATMENT.PLT.%! - MetY:od ai DisposaE
<br /> - DislArtrg to nearest: Well_ 1�� Found ,- {_C_r�.-� ProDenV tine- 'y•'fr •\IX,
<br /> 14 �I ,Ll 1 ---- len thbia^. - •r-4S"'!�r'---- .
<br /> LEACHING LINE Nu. B Length of fires __r=__7.C'-_.-17 _[.-� Total9
<br /> FILTER BED - Distance to nearest: Weil___-- Foundation Property Line
<br /> YL
<br /> - : SEEPAGE PITS Depth �'?_Sue. �ti. L<_='T_`-'____.___ Number
<br /> r'
<br /> SUMPS Distance to nearest: NJei L7L Foul dation=j�-._P•aperty Eine. T—
<br /> Sk
<br /> DISPOSAL PONDS t:
<br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San jw uin county ordinances,state faJvs,and
<br /> 'rures and regulations of the San Joaquin Local Health District.
<br /> Horne owner or licensed agent's signature Certifies the foltow:rg:"f Cerlity that in she performance of the work for which this pe:mit is'twee,t shall no:
<br /> emproy any person in such manner as to become subject to woricm3n's ccmpersation laws of California."Contractor's hiring or;uiycantracting signature
<br /> 'certifies the[aIl•3wing:•'I certify that in the p.rformance of the work for which this p,,,-t is issu,,I.I shall employ persons supiect to workman's carnpensa-
<br /> tion laws of California."
<br /> The applicant must call for all require�dy inspections.Comoete drawing on revers.side,
<br /> Signed Yi' v tuq
<br /> _ - FOR DEPARTMENT USE ONLY _ '
<br /> ^41 —
<br /> f 1;,
<br /> qpc
<br /> cepsod by �, - Date — A ast , lr ,��T w ..Gr L Inspection by_J � l.(ra Dale-_t� �f- Final rnst>lfction by_ Date C3SLodi 369 36�tManteca gn-7104 Tracy $.15
<br /> Appf aril•Re all cupie+to: Environmental Healt?r Pam,;t?$ertric,+s:rlD1 E. H3raltan Avo.,P.U.Box 2009. Stk..CA 962017
<br /> _ AMOhxT DUE AMQ:7NT RE111TT.D -ASH AECENED f3•r' DATE PERtAIT'NO.
<br /> !GC's/ ���1,��{r l -�, Ci •.�r �7...)- r 3-.;
<br /> -IL
<br /> EM 26
<br /> y
<br /> i
<br /> is
<br />
|