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�t —,:APPLICATION FOR PERMIT
<br /> SAN JOAQUiN LOCAL HEALTH,DISTRICT
<br /> 1501E HAZE' 1 ON AVE , STOCIGTON ECA
<br /> �TelephOneI209) 4S5
<br /> 4
<br /> PERMIT,EXPIRES I YEARYFROM DATE ISSUED`
<br /> x'' - - 7-two itie�
<br /> a,. ,r iCoinpiete rip i
<br /> a ;x vA ° "} akt� t Ho' &tkY .d.; 1 ' t�� �.
<br /> Application is tteieby made to ttie San Joaquin Locai Health District fora permit to'construct andlor install the inror
<br /> mm ".harp n esCr bed, 1pp 1 s
<br /> adacompliance with San Joaquin County Ordinance Na 549 for sewage'or No 1852 for Well and the P.rles anA Rig 11onsof"tti�5aedGS in
<br /> Locaealth'DidV+el os y ua}° e! y ygf � i h�
<br /> �rY "?tt �,,Et;tr= s�, ric. �•� s$+i' ¢ " r W
<br /> �+ I
<br /> Job Ad_drass. ��a , Pf
<br /> ���Address �ki �O
<br /> �-U ense�No�,�,y�_Y
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<br /> TYPE OF WELIIPUMP NEW WELL ❑ °f VYELL°REPLACEMENTa❑ DESTRUCTION'0
<br /> � P M STALLATION SYSTEM REPAIR ❑ ��..� OTHEF
<br /> bISTA�NCE 70':NEARE$T: SEPTIC 7 y j gna+ .-. °SEWER' 1NES. + PCiSALFFLD .� ROP,L
<br /> C, ;4 t r ,� d Sr
<br /> s#y"a�+� n r fOUNGATiON x" t:`AGRICULTURE WEL g A� 'OTHER..WELL pTS'S NfP
<br /> INTENDED,'USErFr TYPE OF WELL 1 ARE' NSTRU.CTION SPEC r -
<br /> � ` py; IFICATIONS a
<br /> L IndustriaOftlk�,! .CJ Open'Bottom f�Cl.Mante *�Dia�'of Well Excavation' ' D ell; as g
<br /> rt ,' �i.-tax t wa F >" r 1 xr
<br /> ar
<br /> Domestle Private y, Cl Gravel Pack „ acy ,t� s�g� a of Casing apet+llcrton
<br /> yn.h4urs xy;t &. ..S4a 'xirew v w
<br /> I I Fublic l fl Dcltal�3} Depth Grout Seat gtaro f,
<br /> rrher,i o-
<br /> it �5 ��s Appio epth[a I I Eastern k a 5uAace Sea tatted by
<br /> # a»iOatron �
<br /> Repalr'Work Donee[]� ;Type o p �, + H P ' f x{ State tWork Done
<br /> Well
<br /> db nnl++s� i ,+
<br /> Vylell,bestruchon l�i j, Diameter SeaLng Material atop 5D f" i
<br /> <
<br /> TYPE DF SEPTIC,WQRK s NEW INSTALLATION t I REPAIR AODiTION DESTRUCTION I I iNo sept+c,system permitted if'publicrsevw-(s'
<br /> available within 200 fiiiiC) h P
<br /> Installatrort uveyl serve s'Resraence� Commarcial'�Other y � ,,� � � + t
<br /> ll sea o4vin unh R a✓ x a usU; ti n� x
<br /> Nunber of bvmg unds��?��r t Number al.�bedrooms-
<br /> Character of sail tri a depth of 3-Isar y�,'L.ta. 1` �/'�1/� Water-table depth:
<br /> SEPTIC TANKryi�b iC A TypelMf ' '< R kt $F,ta•+ 4y'yi '•� �'
<br /> Mfg Capacity No Compartments
<br /> n, 1�, i# y +� r '�
<br /> P1CGMTREATINENT PLTtC; + � sr a aa, 1 , " �ral� Methotal Dispose
<br /> ' p ❑+stanee'to niarest?' •Wel.
<br /> o Fo n at+on.. `�' Property L+na-
<br /> _ �� s
<br /> LEACHING LINE' ��°;�� . �No 8 Length of 1+nes�`�'`�`� � � '� yial langthls�xe� •
<br /> roo perty Iwrr,, Lin;.
<br /> FILTER BED �`"'w �i +D+stan"ee to nearest WeII�Q��: >�ol�ndation, � Ps
<br /> SEEPAGE PITS ° mDepih� t S+rah " <r + Numer' '
<br /> DISPOSAL?7?PONOS� 1 gS.kfi,�.,rm„ia Fi T =-'i' s3 t
<br /> SUMPS �� Distane��yta nearest Well1, we r Foundation= Property Lrne�
<br /> gMKYri;ti'Z. f '^i'{'r' � L' M..ItT`. ry 'Y[. i4 V'
<br /> I hereby-.certifyythat i ha4e prepar6d this,application and.lhatEthq,work will be done in',accordance with.San Joaquin couh'i lr ialinsnee� sllit-w4w an
<br /> I and regulations of,lhe San Joegwnaocal Health 03t ict' �{t�r;` I £ ;��r
<br /> Nome owner or:;fcensed agent, signature'certif..a5 the followmg jI cartify'th3t+n the performance of the work for vuttirh hit pe ,t csu B.ha
<br /> amp14 yj;any'poison ni such inann�;:as to become subject to work'man's compensation laws of,California:�'Contractors hinng ntra[tlri#afg "a`tt�fe.
<br /> cenrfiei the'f fft)wr I certify that rn the per}ormance o!the n ark for whrchihis permit rs Issued t shall empioy persona sublect to workgiarcornpe
<br /> tion laws of Cali r +a <M1':,i 5 •'�`f y ,�' , _ a# - >a ,.w..rs' rt'.e
<br /> �_"��heaisro.� y.�s
<br /> {TThe'applica - u cAN rill r i' ape C pleto drawing on Arse side `- - 1�
<br /> a�-m,r �► Y er - 'x�' 'r*
<br /> Signed F STitle� Data• ..
<br /> t
<br /> �
<br /> Appliceuon:AccePted by Date �� "* Arar ■
<br /> _ i
<br /> �+k:* .t;�g r s a ti + i h t�r°a" t �.�': ate
<br /> Prt,Or Grout nepectron by J D1[u Fmel lnspacoon by _
<br /> �� e s y r s �W r s I�
<br /> Additional Comments
<br /> ❑ Stk 4f 6 lsmlWED Lodi Ili 364.3621 ❑ Man Ieca 823.71 D4 iL ❑Tracy'! 835 6385 q 5
<br /> Applicant 'Return sl l capias to EnV ronmentaf Health PermvtjSsrvices 1601'E 4a:elron Ave P O f3ox 2009,Sik.,.CA 95201
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<br /> ,tt'AMOUNT:Dt7E ; :AM011NT,RFMITTED'-:y .CA$H ,, ,'RELEIVED.BY1 PERiu11TNCi
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