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APPL1601 6NtP001 0MAIT
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<br /> N JOAdUIN L CAL�'AI A 114 WSTR CT
<br /> ` U 1 .,�[,NA2tLt0N-AVt ; STOCKTON, CA
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<br /> 6160hb4 065).466-6761 G� [' ' r:-« .,, ICi�mplete In Tliplicatel fZD
<br /> Applicati6h is he!ehy mage to.t'" !�l i��� r, Health bist"rici#iir$peirnit t6 ciinsttut andldr install the work hei de$cribed. this application is
<br /> iri'ade lh o a��iicq�! � e+ ouhtV I'dinatied No MO M l'•$W60e ttr 1460f3S2 foilWe11/pump and the Rules and Regulations of the San Joaquin
<br /> Local 14MItt�tfI tt a
<br /> F lob Attdrei "y" ' �}G' Clty =S C {UN. PM
<br /> LotSize_
<br /> Glr �A! f res C�q z). 0� A?,tAli GE WE—
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<br /> OWner'§ IVanieJ ffa� Addr sUY � `
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<br />'I F4'.N�+[ e1..1 y;d.Sd .ul.� � ., i. JJrr�� r. _� }i"•PySt':� Y :�..a.
<br /> Gonttaef r Vryl °1 t Gr` $, ddres5' S .r. 1�_ Y 1�fr. S/.T.Z �� Phone e!Wo 114 t3
<br /> 1_icen'se I'io.•_
<br /> TYPE Of,'WEL4./ls.,Ui MP j ', ;4 t"I NEW LL Q 1 i i WELL RFPLACEMENt p bESTRl1CTION Q
<br /> f � i1M�iN 1kt h , 0§1` A hgPAlfi,� _ OTIfER l� a` Tdi" &"el 61
<br /> bISTAIy b i Ti t � uNts V r 'b1§i�asAL FLU: PkdP. LUNE
<br /> _allN4 ,=' i1L��LTtSi -VbEEI t A1t61 i 2 17E��
<br /> INTENDEb USE YE Yl� MU ?PRp IEM�1 I Cl7�iSTRI1CTIf�T+F Sf'LCf ICA �O S /A
<br /> ❑ fridu:ilial �i ; dip eit I �ttofit� t:- d Mahtec5 . " 1 % '
<br /> IS r. Oib. of Vh�ell �xcavati6n t 3 bia. of Well Casing
<br />' ,a Ioiitetlt If'riullte Cf.Clibu�I�' k ' " Uat �>tc � $fdsm ry
<br /> i Y Ylt SpeClflr ations
<br /> f 1 f>uhLca ' �thi3f 1s:*, ij 'L della 6ePth of Grout �8a1 �YPB of U`rnelt i"
<br /> I I litigati$H jai �A�ptt9>f blit 1 I u lwh G SGHdce.Sklil In tallAB byi l,ds"�7 d.$ :. 9Jt 4E d
<br /> t Repair IA�oik bbrte df`-' iIVp pit fi;uM���i°�- ,r 'I H.F'f State Work'Uohe if U Mt.it 0 V6. C,it
<br /> Wefi beltuctibfl rj, ihTiiililbl,ef� � r4 a ;; 3§dal}itg�I5litteiiali k0 i $vW ITS :St vRlf Y t v
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<br /> Erif f.INelAfial ii3elb G1ZQor
<br /> TYPE OF SEPTIC WORK ANEW IIJST LLATIbN I1 REPAIR/ADI)ITIDN l i ^ I]E5TRtJCTION I I,INo septic system permitted If public sewer is
<br /> 4 r> �4� 71.
<br /> 1 .:£ zQ k ; *"i t u ! y .�St""�^ tlaifgli{e Iruithln X00 heat.} z. �
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<br /> Number of livinLiini[$ �hlumttber of bedio rti's t -
<br /> Chaltreet;ry� �Mt a a *-... 'VrlatBr table tlepth
<br /> SEPYICAiulk� f�9} ' A
<br /> .I+io. Coi'npartrr►en43 ,
<br />`i PKG. tit ,�tNiEhli 'L1 [ ^ s ' ? 1 g;`f ; ` i
<br /> r i # i k Metho of Elisposal
<br /> WmII , Y Futlfttl tldn ,Prtsf MY Llne> 1,
<br />' LEAC#IINCi lirt, L1 N� tai t#t 1ii lib a is s 3 Tc tial ieii th/kite '�
<br /> I`fLtIx °` � ' Idli�l fi ililitf x Waif` �` btlfidtlotit;spdriy llitr `
<br /> E SEEPAtp.1171 1,4_
<br /> GE ITS I I bepttt Ndriibetrn
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<br /> SUMPS w k d { tif;tahcl3 td ridi�llis! �r IIVeH i �_ .EbtFhdatii3n
<br /> -.-+ur •^r iz•,�^`'p-` �.R.te_ w Y �-prO�B!'tS! Llhe
<br /> 1 heFeb}i Efirtify(kid'Ili vil#ftdliAitid thl ibf?llc fi�r�$rid that t66 Wi5tk tll!flllbli d6n6 iA a'dc6tdaridb with Sah Joaquin eouhty',didinAnces, stat6 laws, and +
<br /> rule3 And rOddialll fli'd##h$ sh:I��4a Law HbAlth bittrlct f, I i
<br /> Home ghbf 8r fiteh$ ii'6iit`fi$i��ti tt ttr�fAi#the#ollaVl!ih� `!1 delfify{h$t iA the perfdrmAnce ti#the tiVafk fol which this permit is issued, I shat!not
<br /> employ ahti arspfl16.Auifi Mfih e.A$is 6,W eubjAct to WotkMehl coM(t-61`1ll9tfon laws bf California."Corilrector's hiring or sub-Ontractino signature
<br />'4 cert{fM the fo11aWIR.' ,� t lty tit iri`�ib I6i'fOrrituled pf lhg Wdtk foi whieh this 014mift is is.§ued,I 'shall Arnploy p&sons subject to Workman's compensa-
<br />[ tlan.Is+Iv$01 Calrf kis vlr' f ,:i f i. _z i, ,<: t s
<br /> 'the,AppNcant. t f fat fl# tll ons Coin I t , r ,tea - � Y
<br /> # drdwing arse sid9r 'F t v
<br /> 115
<br /> Sigttei# t ti '. T! l "filtfa' .t .a ,.s �tdr✓ bale: V&V?o
<br /> �:: t t P it AgfM M ONL1i
<br /> Appficafi6h Acci3trt d bate `j~ �� Area '
<br /> Pit 8r drbut Ills etit it �Y = :4+ ,,; Will � r 'i$ Pinel Inspedtibn by bate
<br /> Additidital L`orhffi& f®I trf�. - i
<br /> ❑ Stk MA-ft.-, �7 Lo�ili= Z# h] MAhtec� 1d$ f� tacji &5 6`3}35
<br /> Appiichht Agtul`h>1i bdpfe! a f rlvirr�FlligfrS stt; Health I�einmit/Sijvicea it3u1 E Heteltoh Ave I'.0. Box X009, S"tk., CA 8$201
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<br /> s 1MF 3,k AN1blIN f+ MITTEb „"tr"F1SH r
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<br /> AMbI11915 ItV (SATE
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<br /> a,E 392�fREV !�ns1
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