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APPLICATION FOR PiKAJ IT <br /> SAN JOAQUIN LOCAL HEALTH PIP 'yam <br /> ` I.W1 E. HAZEL T ON AVE., STOCKTONi CA " <br /> Te(ephorte (2091 466-6781 <br /> EFROM DATE 55UE,a <br /> P_i�g .I..T i 3 PIRE�SS I YA <br /> �.� � -- <br /> (Gomplete 10 Ttipiicatel <br /> ApPr�tlon is thereby made to the San Co ani o dir13`rta .X84 br sbwag Torr,o,t��d construct <br /> w ldjbr pumly wind iiie f et! A8¢ulatf¢n§of 1iSe$#!in Joaquin <br /> @ its compliance,-w.&'Sart Jiragy <br /> L6641 lfeaitiv bistotil. M <br /> ss ::_ y x Lot SIO , , <br /> Job A+ttt'lre Cit <br /> � .� --._._--_..��..._-. -� <br /> ! _.... .-...- <br /> tr'a Name ddress <br /> Phoria T _ <br /> - <br /> Con[taCtrie :. License Ne <br /> 0 U"ON 0 <br /> TYPti OFt�PUMF NEW WELL " GCiELt R i?t . 1 <br /> . SYFrfEM REPIJ <br /> AIR. OTHER C1 <br /> DISTANr�E To NEAA1 BT; , SEpTIGTAT11Lt A�#Ofil �� <br /> PUMP l <br /> TANK __ SEWt:i� LINES t11S1�O:tAL F4t1,_._.-,._.�.-- PROP. L11�tE ._..�,�:: . <br /> su <br /> �.._. FG7UiVL1A1IC�N _ AGRI,G{�1 HE WELL . 111 HER WELL-.— <br /> frt lurlus�riai^�T_ { f yien 8ottnt�n !i lllia_nteCm 6)fS7Fy�tl?N $PtClyRT10NS <br /> TYPE OF WELL PROBLEM AREA <br /> IfiTy17tUSE of Well Cuiro6a. 4W-OExay8.0ia <br /> �petl{lctltlorlA <br /> 13 pornesticiprivate Ll Grave! Pack C� Rect l?PB <br /> r, Public i-1 Other <br /> 17 tlieite Depth of Grout Seal }Y{�'d1 1i1'trllt.�-__._..,.-.--�--r-• <br /> ____.RprirriR 90013 ! 1 East©rn <br /> Surface Seal installed bY.�-w------ �--a- <br /> i 3�IrYi"tfon �� <br /> Repair Wak Dante U Type of Bump - #i:P. �—____-.-�_T-___.._ Slate Welk 000.6 T <br /> Well Destruction 0 Well DiariiifO _ Sealing Material (top 501 <br /> Filler mi)twial I13elow W1. <br /> Depth . <br /> TYPE F 5�P6iC 1N RI4 STALLAT014 f 1 f}FPAIfii'A 0IT161 f3E TEIUMON I ! INtt UiPtlt ayYstet"pdrmitted If publid$ewer <br /> a�ralil8�fill wiillin 2UD t8k:i' <br /> ttrltiilllation wfd serve: Residence £ammerclaltxtller _:. —. <br /> Nlrtntler of living units: 04 <br /> trlbto depth <br /> ktraracter of soii.io a 00pth of 3 teat: — -— <br /> ti Capdeity� No, Cbttlpd irmots <br /> SI;PTIG T�1NiC L7 TypeilMig ; - <br /> Illlhthm of Dispo ill <br /> PKtt. TREkTMENT PLT. 0 <br /> Distance to nearest; Well �__..__T `Fawtldatitsn_— _ Ptpperty;iin>y �.- <br /> 2 a„ , <br /> t EACI fFIQ TINE No. 8 tenglh bi linesr - - TokaLfer,gitt�salh r__ <br /> FILTER 41110 pistaned to rarest: we[, ►>i�� Eouitdataan �:�_— I'rope►ty Line <br /> umtsei.�� _. .� <br /> !� <br /> SEEPAGE <br /> PITS 1 €Aapth : ----Sire' <br /> StIMP+B L:! Dlatarvee to <br /> nearest: Wall Foundation Property L'070-Zz7w--.a_ " <br /> ` I h fOS CertifyP Mthat i^havee)prepared this application arta than tyle work Wll1 be done in' aGMdance wirh$ta+x�rtaquin toul%t�f�idirti�l9tsa§.91atA 18+k3, and <br /> ttfl8s and regula4an#s of the sen .ldaquirt La l Health ti�l§tr,cr. 1 llt9d, 1 shalt not+ <br /> �. Horne oWnai or licensed agents sign&L"cef Iles tttie tolfowing; "I certify that in the pea,ormanrsg of the Work tot Vklu�h'�*.`0(fit. <br /> tai'a pgneon In such rr+anntrt a5 t8 tsiicorng aert?ject to workman';campansation taws of dalitornta. 6:anikHotrrf�.�l�tit'1g tit itufrt�Dnttheting signature <br /> cart3ties tFte lallowingr"1 certify that in ttid Iier{i3tiilahca of?the work for which this POE 0-i is lss.uetl, I'sttati eigp#ofY W'�tsbrt #tt1t W�G 9WaWttrta;rl's tompansa- <br /> tion Paws of Caldorow" <br /> The*pPtiQwffqUstj3rj far Ited inspactidns, Cpmpk®te drawing on revam5 sfito. <br /> Tina: <br /> S baw <br /> : -Olt p ¢R f MEf 1 Use t 1wr <br /> At1is3 <br /> Applieattttfr Accepted by <br /> a•!' _ dte <br /> Pit&-Gtntrt Inspection by Date Pinter Inspedtion by <br /> Additional.ConwiOnts; <br /> 0$tk 4WMI 0 Lodi 369-36Z>t ❑ Martflsca &.041164 n Tracy 6r&viii5 <br /> i Apphon p'atuM ski copies 4o-,Environmental Health-Permit/sprvicea Itol E. Haxelinrl Ave,, 0.0,Box 20M <br /> Silk, CA MI. <br /> iN E AMOIPMT OU4 Ai IIlIMO ki I1EN1i r1 Et] it1 C1 IVEtf @lY CAtt PEIIMI I'Nq. <br /> . �------- `a <br /> 7%1 -�lc� <br /> r EH'1bt41WEV,tf.4b1 <br /> EH 14.26 ` u_ <br />