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* -PPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON., CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> p (Complete in Triplicate) <br /> ? to conetnrct and/or kntall tiw <br /> Work beret,descriaad.TMs spoloation Is <br /> Application is hereby mads to the Sasr Joaq an Loosi ceNti7 60for s Oar and tt a Runts ReprtieeiorM d the San JoWlitNt <br /> meds in compliance whh San Jos7ui�County OrtNnW+os No.619 for sews9s or.No.1882 for weN/pump <br /> Local Health District. <br /> Job Address +} <br /> Ownses Name <br /> Address Q S License No. <br /> Phone ` <br /> Contractor VttEt kC!E ENT DESTUCTION O <br /> NEW WELL O TYPE OF WELU�M © OTHM1 O <br /> ' — PUMP INSTALLATION I I ,� <br /> ,i#, PROP.UNE <br /> '« <br /> DISTANCE TO NEAREST:AREST: SEPTIC TANK <br /> AGRICULTURE WELL .......- gp <br /> � FOUNDATION - OTHER <br /> ,CONBY'RUCTION'SPECIRC�► g p <br /> INTENDED USE TM u+ 4 ' d C" <br /> tt <br /> (3 _ Open ..� <br /> ❑IDomestic/Prlvate O Grawl PaokF `�} of Grout � <br /> i � tw - C <br /> Publicrdpt ❑ <br /> L1 _ pprox „. Eaalattl�, �r °Srry}ape D" <br /> 0 1 k Work Done ❑ Type d PunMt <br /> Rent �^ W SaaNnO Mawlsl l }8fY! <br /> WeV.Destruction O V"OlWmar pNM MMMtd t►�alowvll0'1 _ 8� sewK Ir 'x Cly <br /> DsPth (No 1R ,exp <br /> Cl f�'AiR/AaDlna� D <br /> TYPE OF SEPnC WORK: NEW INSTALLATION <br /> et` <br /> IrtetaNation will Parva: Caftv"e 0IM <br /> Number d Nvkq unNa: NtatatWi'j`�I�►``i;,s W1lsr"WdspCh <br /> Chw*cter Of ON to a depth d 8 Net <br /> N y tit►.C1rrllP+tuM^K t---.�..'� . <br /> SEPTIC TANK Cl /� — '`MathOd of'DMpo+M' C <br /> PKG.TREATMENT PLT.O y PlOpal i t =„ <br /> DIstW�oa t4 naataat: tM�+,ri.r+rrr;P W luta i, r �y,c <br /> T� No.•LtMgth d Ntlaa f �'"'.` ""'Toa!N�nptld <br /> LEACHING LINE ; <br /> Patllllwtlatl � "-.w+...hOPMIY.LN1e.. , <br /> FILTER We U DkWw 10 1 <br /> ITS <br /> O Depth <br /> SEEPAGE PPropartfr Una..:�..-.•- ' <br /> SUMPS O Distanoa to f4wow Went.•-�-.- <br /> DISPOSAL PONDS ❑ adhionm MO <br /> I hereby urtiM then 1 haw P PWW"ap111101 ett WId thrt tM g1Wit tent br dWMI k't aaaardsna with San Joaquat <br /> d tM wak fo►'wMch dtb Is issued,I Irk int ndt' <br /> now and ropulstlom d tM San Joatlt+kt L�� .'«I #*Mt tM� a <br /> emploo~ <br /> ' of No@ any Mason k+such nrnr+Wa W►to baobma aub(sat tb wo +�na contpWwMa+Mywa of C�a�Nlertrtis.rC.tnLraacyto�►'yyhM.inyO �o <br /> ' tf In tfla pWfanttWtoa Otla lrw..^..�b*j4�*Nw'gfty ��'^��`7'iQt V/, �F <br /> s-.« cartlfiN tlla ioNorMn9:"l ow" d tlla wak l�.�-..• <br /> on Iaws of CaMoeNa•„ « <br /> akN. <br /> The apakeM oNl for M •� � ""'"' Dm:aft/+Ir-d <br /> SIWwd t ; <br /> Pal!DIPARTMW U"' <br /> Appkelon Aft e'.=d by Doi <br /> rhnl k'NMotion <br /> Pk or Grc„t Mrrw.don by <br /> + Addition.l Cwrww": 82}71 <br /> MWtlsa a O TraOy <br /> ❑ O AppNeWK Ralllfn aN eopMs to:EnvM mntel Health PWtWftfV Oaa 1801 E.02111011110111Ave,.P.Di NIWwt1009,YSdr.. 9�t t <br /> 10 <br /> FailASAOUNT tIN! AMOUNT ;:.Ilea YM W IIATN r/���' <br /> a u <br /> WFO <br /> •aN Ifi►111EV.� �e� <br /> r1ri;,_ <br /> e� xy�01 <br /> e <br />