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<br /> 41 19 ;
<br /> APPLICATION FOR PERMIT y4� ?
<br /> SAN JOAQUIN LOCAL FfCAtTI'I DISTRICT
<br /> 1601 E. HAZELi ON AVE., STOCKTON, CA >
<br /> Telephone 12091 466-6781 =haTP �� �R• :
<br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED
<br /> r F� Complete in Triplicate) 5�,."'d0{O '� + �a� {
<br /> Application is belch made to the San Joa;uih Local Health District for a permit to construct and for install the work heroin lest nbtK;:'T1'+s app,catlgn is
<br /> r li t a ns of the San Joarauin r
<br /> 1 # .App Y
<br /> made an compliance with San Joaquin County Ordinance Na.549 for sewage or No.1662 for well end the Rules and Regulation
<br /> w 3 f`t,
<br /> } tai \lyra a
<br /> % i Local Health District:-
<br /> I-, A. �y i 7
<br /> City Lot Site`Jtya n � r 8PM( 5id
<br /> 'Job Address y
<br /> Owners Nam
<br /> r: Qt'J.�3 eri�f� 5d' lI
<br /> x< „" p4 qd Address_,�L[? License"No: E�---- �
<br /> i•p'�sx � Contractor ST� -
<br /> WELL REPLACEMENT C7_ OESTRUCTION'C11� ^'ar""'
<br /> 5. * ltt TYPE OF W MP: M, NEW WELL D a k i ,IA�'3'''' L
<br /> aria +, MP"INSTALLATION C1 SYSTEM REPAIR © Y,OTHER.d
<br /> :DISTANCE TO NEAREST
<br /> SEP NK SEWER LINES DISPOSA OP°LINE
<br /> r� *i 6A elk
<br /> OTH Wt?LC� '_-PrrsisiMPS
<br /> Yx, f Mt; !A"1't
<br /> jN7ENDED USE' t TYPE OF WELL. P DBJ~€fN AREA CONSTR G SPECIFICATIONS a �
<br /> �"�" t' Dia.of wall Casing
<br /> Hr C]Ir.. .3trial O Open Bottom C]Manteca of Well Excavation
<br /> ` r GI DomesticlPrlvate D Grave!Pack El Tr y+� of Casing r Specrfacatiorls4..
<br /> Delta Depth o Seal Type of Grout "R"
<br /> �Y7 f'I Publ€cv �fl Other
<br /> " � .T !€. Depth .', I I Eastarn Surface Seal Insta f s _.
<br /> l lrrigalian S >i.F. State" ^� , .
<br /> I?vim
<br /> J_Repair Work Done ype of Pump '
<br /> Well Dest n C1 ~Well Diameter Seahng Material Itop f0'S 6?,
<br /> w r r Filler. . Below 50') "
<br /> n sxd Depth
<br /> �� TYPE OF SEPTIC WORK NEW INSTALLATION 1 I 9FFAI A DITI DESTRUCTION I I lNo septic systam permitted it public sewer'.
<br /> + y r + w k available within 200 feet.1 '
<br /> installation ebll serve r vR Renee Comrnerc�at Other . N f�
<br /> 1 F 4tr' r�f
<br /> d rA Number of living units, Number.of bedroom , xa :, z - .ypw'• § , y +'�r � �7" r
<br /> >- tr Water tibk'dept�h >if i
<br /> .1 Character of soil to.a de th.of 3 feet: -=- #
<br /> p rV w 3 .Ca.d ty Rrttents dr. :'. A
<br /> SEPT[ 0'4'E] TypeJMfg' ' , ko'Compa ,
<br /> "Ti t`s'e PK 'TREATMENT PLT Q .. a ::",]L•''n,Y;;ti r b. r x
<br /> Distance to nearest:• 3 Well FoundaLon Pro ,JleL3olttiz4xR
<br /> '
<br /> ."aIf
<br /> LEACHING LINE ai No &Length ol'linea ti
<br /> r a Proporty,Line
<br /> {
<br /> FILTER,ER BE {C] Dist to nearest, Well', �� Foundation_ r WAR
<br /> �4�4,a,rra' � '� .rc.. .r„dn.•r•7 -.� .. ,'.,.t r�"}«l
<br /> SE°PAGE PITS y 1 1 'ITe;lh '' 1 Z Y $i
<br /> �1LASNumber a
<br /> Distance to nearest: 'Well .Foundation PropenY.Linet �f
<br /> .,L,,. . .,i, _:. .:r'Aq. t ;;, j- 3si!. .:c 'f: t`. ° '.':tv:T•r4�F} tiT3.991 7`v,.
<br /> � N-OfSPOSAL PONDS' en< _
<br /> �fl 1 heiaby certify That f have prepared this application and that the work will be dpnu in accordance with San'Joaquin county ordinart€m,state Taws'cad
<br /> rutty ante regulations of the San JoaquiA,Local Heaith District t'.
<br /> e�, r9 Holm owner or licensed agent's signature'tenifles the following:"I oe`rtity that in th,t performance of the work for which thk permit M isuied I shall not°
<br /> .� : emptoy any person in such manner as to become subject to workman's compensation lawn of California. ,Contractors hiring or sub-rontraclirtg srgnaturo
<br /> 1.;t .�}.•certw"the foAowln I certify that€n the performance of the€work for which this perri-A is issued I st€alr employ persons subfect to workman's compensa
<br /> :x � "t€on:lawe af;Galifo
<br /> 1' { �
<br /> t: r, _;ul ,T}u apprean u' ll for r omplete'drawing Dri rover
<br /> Signed r";" J t r^ nF1�7t
<br /> _ •.° '+"r'� �y a...,.�, Ty_. �. - .k� two i,
<br /> FOR DEPARTMENT USE ONLY e axfx� 1` F
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<br /> a; Daze Ares_
<br /> z '4.Applieat c n Accepted by } nL A � --
<br /> ,.v ,
<br /> Ps ''Pu or Grout Inspecrxsn by Date Final Inspection b e
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<br /> Additional Comments41
<br /> 1 C]Stk 466 781, 0 Lodi 364.36211 ,:Y. Ment ce t323-7104 ©7ratY Y t ^
<br /> Applicant Aetum.all copies to Environmental HealthPernut;/Services 1609 E. Hazelton Ava -P.O.Box 2009 Stk..'
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<br /> CA 9
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<br /> FEE ,'!.AMOUNT DISE .AMOUNT REMITTED CASH - RECEIVED 9Y DA(E ;•PERMlT'ND.,=h
<br /> "'1 ♦EM 1131 tntV.tr90
<br /> fro, EN 1430 • CaP( ,� '.S ty
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