|
APPLICATION FOR PERMIT
<br /> SAN JOAQUIN I OCAL HEALTH nISTRICT
<br /> 1601 E. HAZE i ON AVE., STOCKTON, CA
<br /> Telephone 1209) 466-6781
<br /> PERP,11T EXPIRES_I YEAR FROM DATE ISSUED
<br /> (Complete in Triplicate)
<br /> Application is 1lereby made 10 the San Jr Ig1rn Local tlealth District for a permit to construct androf install the wort.t+,•,r',
<br /> made in compliance with San Joaquin Cut nty Jill-v".0 Nc.'.vF9for SewsgO M No. 18621ur wctl'(wmp And the RUIN,
<br /> Local Health District. d�iiec"�
<br /> 1�n/� �J /'1���. �t si.. 1.1c!(� +n
<br /> Job Address -l--lG'!�H/�/`If14 �V,)FI-.41,-kill(f�a
<br /> rt. l
<br /> ..,. I
<br /> Ow5ncr's Name 77Z'P 1�7�l'7rC1", �f�' Address r
<br /> 5ru 71n -- 37[ 01 ►�• .. �54:j 3':
<br /> Contractor 7.. . rt 1•r Cc __r: -J� i- t.l:�L '
<br /> TYPE OF WELL/PUMP:
<br /> NE vv WEIL WELL RE LACEMENT 1 , DESTRUCTION
<br /> - / y
<br /> PUMP INSTALL OTHER INSTALLATION SYSTEM REPAIR !1
<br /> SEWER LINES _�_. DISFOSAL FLO. FROr LINE
<br /> DISTANCE TO NEAREST: SEPTIC TANK S
<br /> - - -
<br /> FOUNDAI ION AGRICULTURE WELL OTHER WELL PIT!; Sl1A1P_ _
<br /> INTENDED USE TYPE OF WFI I PROM FM AREA CONSTRUCTION SPE CIFICATI06- D A t Well t tan 1
<br /> I I Industrial^� I 1 Open[Lotion, (.lantrca Die. of Well Faeevallon__ rS----
<br /> ��
<br /> 7 of CasihM11� _. Y�'{• Sprc:f.catana CK�tC� ri
<br /> (.1 Domestic/Private l 1 Gravel Park I 1 Ta1.y y1� Type of Grout r
<br /> ('1 Public ��fher Delta Depth of ti1M11 Seal
<br /> /�I 1
<br /> I I Insgalron w Apptoa Del tit L^tom Surlaie Seel Irnu1NA by
<br /> Repair Work Done I 1 Type
<br /> of P,11111, H.P. State W1xR Done _
<br /> Well Destruction ; ) Well D,anu•1,,, Settling Malarial(top SWI
<br /> Depth _ F111tt1 AfaterlJl(Below 50')
<br /> IYPE OF StrTI , WORK NFW INSlA1I ATIDN 1 1 111 PAIR/AnDlllON 1 I DISTRUCTION I I a1Wt>le1w�hr?R1rlrPlrlted d (g1t•1.1: srwrl rs
<br /> Installation will serve ResiAenca Commerc,al Other
<br /> Number of living units "hnrbr. ,•I brilu,nnn -
<br /> _-- wafer tsWa rlrt•th O
<br /> Character at eod to a(lrtp(T1 of 3 ff,el e-rty-
<br /> Cap. No Crxnperin", ---
<br /> SEPTIC TANY IYpr• "At{ Method of DNu)%sl ----- —
<br /> PKG. TREATMENT 1.1.1.11
<br /> Distance to••••.arrcl Wall Faps I;Uo-
<br /> m.lation _ _ Pro
<br /> Total length/tile----
<br /> LEACHING LINE--- I I No. I1 Lenp•h of ImPa FOlsfl�tklll�`-^ Prry Line BED I 1 D1stAnc•en „r•areat: WNI
<br /> ----_-
<br /> SEEPAGE PITS r-ie
<br /> SUMPS DAtan-a I., •,.a,ee .
<br /> --- —
<br /> •—
<br /> DISPOSAL PONDS I 1 _, _- — -' -
<br /> 1 Iwrehy cllrtlfy that 1 have pre(MI«r,t n ..;•t,11C.;,u•,nit t IIM wcvk w N he Aone a,s. o d, rn wnh 'inn Joaqua,c aunty ordnance%, stale i.w+ arw)
<br /> odes and repulrbrn,s n1. the San.InAq,r.n ,•r sl ttsahh Drslrtrt 1un,••1u n If tivs wolf, If,wt•• h this pwrrnt�".1aue 1 I sash not
<br /> Homo owner or IirnnhsA agent'•s,1lnMurr, .rUtlns the tnMnwrng "I rarely that Y,MI Des ,r(-e1 r ons l wluacla'e h.nrw M wt,colo-c.lruj1 c,ur.•t,r.•
<br /> employ any person In lull)manner as to 1 mn ulhlnta In wal,kmar'a com{»n
<br /> esrtAwe IM following "1 ca!hfy,lint,n the 1••r1.„rmnnce n1 the work fur whkh this pwrrvt..,a`und I shall emMOY 1*�w`s a"Duct to workman's comlwr,sa
<br /> ,it 1 laves of Csldomis."
<br /> T.J epplirm/ ust rail Int all fortis"rd In%(Mctiom ComrletP 01-1 tg cel reverts side.
<br /> tin � - PWk4 : ' � -
<br /> Signed Rrrt S-t,, ^rj, E fj�
<br /> $417-7r-L
<br /> FDgI��P ff�t18E UNI.Y � � '^•
<br /> !'
<br /> P,
<br /> Alas q� _�. ..��� _ -�
<br /> Appticetbby n Accepted `` 1 Date, _
<br /> FInM la>tpeetion by __ -.
<br /> Ph or Grout Inspoctlrn by - - Dat•���,�/ / J
<br /> 100Additional Coenm:rnts _
<br /> .__.._�. ..
<br /> I I Stk 4686761 F l 823-7104 T
<br /> fwy Lodi 1"1 t1r Atar raf!$•rvkp IWI f. Aw�P O. Box 2001,Stk.. Cr1
<br /> Applicant- n,turn all copt"s to 11..
<br /> -- fltCFIVIO ay PATI ri nMtl r
<br /> ,,,
<br /> I/I O _. ..- ...... � ` ��. r1. •
<br />
|