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jI APPL,ICATIOfy FOR PERMIT
<br /> SAN J©AilUI3V'L6CAL HEALTH DISTRICT
<br /> 1801 E. HAZEL i t)NVAVE., STOCKTON, CA
<br /> Telep}»ne J209I 4&8-6781
<br /> PERMIT EXPIRES''I YtAWFROM-BATE t156t)6t IC aJ�
<br /> w,. (COttrij�et'-!n Triplicate) ;v K .{ ».! r
<br /> �Apioko'on is he r- j"d •w. ; r'+. rf C it r'!t ,ftr ,
<br /> leeY mach to the San Joaquin Local Health District for a permit to construct and/or inti the work her*"'deacriberfi
<br /> i 0081 in compliance with Sen JoatAri+t County Ordinance No.549 for
<br /> Local Health District. >w'�w•:-. z ,rsr Nn. 1M for wan/Durtl�and th his appticationu is
<br /> in
<br /> i y pump ttttl
<br /> ts:3,r":, .;,•« y v,w bias and Regulai,ons of the sort J
<br /> ,_b .J 'rte"y , ' +may
<br /> JW Address AC._ JJ,P M �. ^ /.uu L� � >ft� �j; :A.. �,y+V`�Y Y',i..� '•�/ In
<br /> w.rLo .�.�12@._J""�� 'P� ~•'
<br /> owner's Name 4{0:r„ '.?
<br /> .' Pham
<br /> Contractor ✓R, s —
<br /> Address. J
<br /> TYPE pF WELLlPUMP: NEW WELL Ci _ License No ��Phone
<br /> PUMP INSTALLATION' G " WELL REPLACEMENT C DEg7AUCT10fM D
<br /> DISTANCE TO NEAREST' SEPTIC TANK SYSTEM-REPAIR L7 . OTHER D
<br /> ----- SEWER LINES �"�_ DISPOSAL FLb,. ' _ #
<br /> ti FOUNDATION'% AGAICt3tiIIAE WELD
<br /> �`"""I"`*tNTEiVDE�D U8E +r,'t • x"'.m --- OTHER WELL 1 p
<br /> PROP. LINE
<br /> _. TYPE OF WELL PRO81£MAREA x .'-- 1SUIUPS —_
<br /> (..i Industrial COld51RUCTiON SPECIFICATIONS Sr '� r` j' :.. "�
<br /> "^�a CI`(yp ,.Bottgm t7 fiAanteta Dia, itf Wal! Ericavat,ort w*i
<br /> L'Domestic/Private G'Gravat Pack = Die'b,xWeii Casiri r"�•S i�lr
<br /> L Tr
<br /> rl Public D Other Typo itf Caging
<br /> C 1 Dalry depth`of Groat'Saal �► , • pecrfications
<br /> Irrigation . "� _.� _. "91\ `r 3 i r
<br /> Approx, Depth ) Eagtcrn " �r a Vpe of Grout , t ' _
<br /> RaBir Work DonePump _ _ _ `4$urtata Seal'Installed hy,._' " \ "ky
<br /> _ Type of r
<br /> Wel! Oaat►uctiori t "—_ H.P.HP ------ State Wo*t1One,
<br /> Welt Diameter . r }.k. -4 ---"�
<br /> Sealing material(top so').. V�
<br /> W
<br /> TYPE Uepth" _ - Filler Material (Below 501)
<br /> OF SEPTIC WbRK: NEW tNSTALLATiON. REPAIRtADDITIOA( DESTRUCTION (::' INo septic gystam
<br /> Installation will serve: Residence t - permitted if'public•sower is
<br /> �'- Commercial_..—.. Other— available within 200 feet) � ».y
<br /> Nurribsr of Irving units: _ V Num — rr jJ1
<br /> ber of bedrooms
<br /> Character of�tioii to a depth of 3 feet:
<br /> �s OTIC rAlvic: _ i
<br /> f Type/Mfg _ �� —.Water table depth_
<br /> - ��-- _ .,
<br /> PKG>•TREATMENT PLT. 0 - �'—fi r_ No. Compartments --„_�,_-!ice ' t
<br /> Wei yep-- Mathod of Di
<br /> y � t` Distance to nearest: .5t� ��1 ---___._——�� •S ,
<br /> 1 ¢ mon_ PfOPerty Line
<br /> LEACHING LIN
<br /> D No,&Length of lines __
<br /> FILTER BEDD Dalliance to nearest: W� --- Total length/size
<br /> ' astitttlallOtt _
<br /> I Property Line
<br /> 4EEPAGE PITS 0.4'Depth-- 4t
<br /> SUMPS O qDisterwe tb rAreatt Number
<br /> '-DISPOSAL PONDS is 1 `� .. ?' oWda ion_�"_�1 'vProPerry Li
<br /> 1 hereby certify that I have prepared this application and that the work'wili be dorso in ac Y= +
<br /> rules and regulations of the'San Joaquin Local Has" District. ,'r - �'�h San Joequi county ordinances, state laws, and
<br /> Noma awnar.c>r"licensed agents signature certifies the following:.111 carp` : j ~ � `
<br /> employ any Person in such manner as to become tub tify tha�t in-thb Irarfomtanco iy ,the work for wh this
<br /> cart flea the folbwin pact to work+ltan's rad nsaton permit is Issued, i shat,not
<br /> g:"I certify that in the parformence of the Ia+n+s Of Califomia:'',Contrac'toeg 'ring or sub,-contracting signature
<br /> 'tiOn laws of California," wtxk-for which this perm&(s ia�eued,I shell mai', ?aY paraOns ti
<br /> The a + r r-, "/ ) 41k' t y� y ��DjeCt to workman's comgensa-
<br /> pPlicanr must coli fa uirad.'nspectlons. Complete drawing on rel arse s(de�/ w t
<br /> Signed X____-_— !. >r'" 'i•.. .
<br /> Dow
<br /> T3IIg�E 6gi:y
<br /> 'Application Accepted by � EzN._,�
<br /> Pit,or Grout Inspection b # — Ara
<br /> Date //bV
<br /> Additional comments; /I �t3621
<br /> _ _ /,C.5tk 4664Ml iu amaca
<br /> AopScartt- Return an 71b Ei Tracy —
<br /> copies ui: EnvirOnmentel Health Permhl5®rv(t�& 1601 E. Hazeftorl Ave., P.O- soxR
<br /> 3009, Silk., CA 95201
<br /> wT A11 ( pDp;"" •" AMOUNT REK41TTM ••"C
<br /> 8N tib tAEV r/g'sa f ' .�5 CASH 0=076Y
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