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APPLICATION FOR PERMIT
<br /> SAN JOAQUIN LOCAL HEALTIA DISTRICT
<br /> 1601 E. HALELTON AVE., STOC:KTON, CA
<br /> Telophnne 12091 466-6731
<br /> PERMIT EXPIi'3F_S 1 YEAR FROM DATE ISSUED
<br /> ICDmp!ete u) Trip!icafcl "
<br /> Amd.•nt:un Is f.glehy made,••the Sari.joat;utn Lnral Heatth D,sfnct for a permit to cnnStrJci and'or mitali The work herem described i h!s application is
<br /> mad.fm rn-phdP.:o w0h,a• uaquin fuunty Prrlv,ance ir., vt!)for sour,yre nr Nu IW.2 rw well pump and I' Rues.fnd R".1atiom of Urn San Joaquin V
<br /> i CCC/// V^•w
<br /> Jib Jiddres(..,Locil Pit-Olm Ow."I/
<br /> Gov�OC: .1..�..__ Luf Siva .� PM�-----1 3
<br /> 2
<br /> Owner's Name] i,(-) .-_.JJG�L-�1 Lr Ar'rtrr<s r v •_.y. i.._.. /.G l��t _. :L'�L G!onnrw �/ ��'��'�-'--� 1 I
<br /> Contr+ctor�� l /� �i t11 �LU�'�1Anc;•rtit�'�' -}i��l .'! l '. . _.)�',G, e.•.L N. (`hont 11_sL_I - e
<br /> TY"E OF WE 1+- Nf.WWELL IVELLtRE1tAc,MENT UFST;'UCTION ^
<br /> POMP IN:TAI CATION (/" SVSTtiM REPAIR OTHER (7
<br /> DISTANCE TO NEAREST', SEPTIC TANK .._.,._.,-... SEWER ,INES ... _. __ DI!U10SAL FLO _____ PROP.LINE
<br /> FOUNDATION -_ AGRICULTURE WFiL _. OT,fFRWkLL . PITS/SUMPS .._
<br /> INTEN1 ED WA TYPE OF WELL PRORt EM AREA CONSTRUCTION!SPECIFICAT'ONS
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<br /> ('yiuusrnal f:Open bosom ,-Marvr•ca Dia. of Well E.camvon ..___ .. _. Dia.of Well Casing _
<br /> Oomesfie/Private i'.Gravel Park Trac y Typo of Casing Specifications
<br /> I'I I-oblc , 'I Other I I Dena Depth of Grout Sea! .___._- _ Type of Grad
<br /> hngahpn _ Aplito. Do it, I Easter:, Surface Seal Ir,stallod by_•._ ---
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<br /> Work Done I ' Ty(rn of Pump ll+.J•1(.�... ... H P _If-5. .._. ,.. Srste Wnrk U e ,71•{.v :_y"!��
<br /> Well Oestruchnn Well Martini- S, -ng Alalonal Idyl;0'I
<br /> - x
<br /> Depth ... F-,tlr• Material 1Heh,v,5A'1
<br /> tYP( OF "11'!H �^;ItRK NEW INSIAtiA'!^t_ n(PAIILADDI)lWJ Ot';IFON,T,ON INn•„qan:»srompermrnal A ptlhIlCwwer,s
<br /> a,,sash:••wrtbm 2(0 feet I
<br /> Imla!lat.on wll st-vn Residence _.. Cornmetbal SI
<br /> Number of hvintl ood$ I Numtxa of tx•ttmor♦ _ L
<br /> Character of still to a depth of 3 feet _ miter table depth. . .__ --- V at
<br /> SEPTIC TANK I i typet Mlg No Compa,tnwnis
<br /> pKG TREATMENT-I'L1 i . ra,•+hod of mspnvii
<br /> Distance to nearest Kell Fowvl,ibn;, Pwl-1,v Lam
<br /> LEACHING LINE (' Nn, b I ength of Imes Total -
<br /> FII TLR RED I Dettence to nearest WNI Foundat-, Propiwt Line
<br /> SEEPAGE Fill!; l I Dopth _ _ Site _. f:und,nr
<br /> ' SUMPS I Untantm to neatest W-11 Foundatir,r+ _ ProPeer line
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<br /> DISPOSAL PONOS
<br /> I I,mtr!ry comfy that I have fxnpare,t this application and that utn w:,,k wl:l txt dune,n acs r.fancc wart tion.joaquin county ordinances,state laws,and
<br /> rules and regulations of the:Ian Joaquin Locii Ilei lir Olkmct. L
<br /> Home owner or licensed agent's sronatura eortdlus the Q+Nowetg: -I candy that,n the pntnnnance of the wwk for which this pertnt is issued.I shall not t
<br /> nmploy any person in such manner as to become subject ro workman's compot-wtxrn laws of Cahlomw.'Curltactor's hinng or sutrrcntracting signature
<br /> certifies the Following: I" corhly that in the par4JrmJnca of the work for which this peesut is sued.1 shad omptoy Parsons wbpcl to,arcHkman•f cpmlMnsaPit Is
<br /> tion laws of CalAolma.-
<br /> T he Rpphcsn;ill t call for all rvqu{f1IF ms C ons.Con-1,101”dtowmp on(eversx sxlo ,
<br /> / - 7(
<br /> Signad X. CJ Tito Dats:
<br /> 1FIRR DEPARTMENT USE ONLY
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<br /> Application AccaptoA by q. .�......1�-'----L - _-L--- Area
<br /> -,�w,3.`4o.a,�...�--......_..__ Data r s>;•:
<br /> Pit or Grout Inspection tit -__ Uato. Fioal Inspection hY
<br /> -_...--- "__.—.
<br /> Additional Comments. — -------'--'- "— .:
<br /> la Si:. 4A6 6781 L)Lodi 363.3621 D Mamece 823-7104 i-1 Tracy 835 G385
<br /> Applicant• Retu_ ^"ropias to! Gw:ronmanttt Hoolth Parmn/5emces IWI E. Harotton Ave., P.O. Box 2(Y.)9, Stk.,CA 95201 y ,
<br /> r FCE�- AA�OUNT DUE .Al�SflONT Atm+;CLC r tKc�� AF.CEIVED FY DATE PERMIT NO.
<br /> . LH rt U2.IRI,/ , . I` tV CJ 1 Jt o V /Z / 1�� -k1--�-�J
<br /> LH M L____
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