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l0 k <br /> A. <br /> -, !I t 1 <br /> �... <br /> I, <br /> 3'. <br /> APPLICATION FOR PERMIT <br /> ^ I� SAN JOAQUIN LOCAL HEALTH DISTRICT r..- <br /> �� 1601' E. HAZELTON AVE., STOCKTON, CA Slrl <br /> Telephone (209)466-Ml <br /> Al it PERMITEXPIRES 1 YEAR FROM DATE ISSUED. <br /> iComplete in Triplicate) b <br /> Application h hereby made to 0,San Jopuln Local fiealth Difflim for a permit to conamt t emdlcr knta0 the wMk he+eYt dMa�O ft �," <br /> made In compliance with San Ju aqukr County Ordinime a No.519 for sewage Or No.10112 for WW Puregt end tl+a RrMe and <br /> Local Health District. 1� dim <br /> rpt+ �Q_ ��.�-- �w-�- CItY� 'I1� Lai S11r <br /> .lot+Add <br /> " rap _, "" <br /> p ._ _s Phone <br /> Oa <br /> rE� werer'aNa � � Address <br /> �• <br /> ha • • , License No. Pttorra <br /> Ccntracl Addre» <br /> YPE OF WELUPUMP: ;i NEW WELL U WELL REPLACEMENT C7 OEBTRIICTI�I <br /> PUMP INSTALLATION C SYSTEM REPAIR U OTHER CI sir <br /> DISTANCE TO NEAREST, <br /> SEPTIC TANK _ $EWER LINE$ ..,,.,.�� DISPOSAL ftd. PROP.LINE <br /> i r FOUNDATION AGRICULTURE WELL OTHER WILL PIT818UMP8 <br /> INTENDED USE .I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F?d Industrial A Open Bottom U Manteca Oie al Wa6 Eeavetbn ., 1 OIs,of Y1irA Caekq <br /> . . <br /> ❑Dcffwr lPrMab O GrerM PetJr 0 Tracy „Type of , ld <br /> k _ _ <br /> O Oder L0 Era n SWOM SaN Wnt NMI. StateNMIor 2"A” ¢ ^ <br /> Repair Work Done ❑ TYPO M PUMP H.P. - <br /> We1l Datiuction C " we Dlanwtar ,,.�.�.. Bee"Mm" <br /> X: <br /> OF SEPTIC WORK Depth FH1ar Materiel 19aiaw 1 <br /> NEW INBTALLATION C1 •R R/ DIT'ION 0 OES b pubic SeNrtr i s i <br /> avWibla IMthln cLI <br /> Imstallatkmvrje nrw: Raeldirtea �...�.Oer++rlttareial.. Othlu <br /> 'Number of Wing unit: Nuit of bodmoma <br /> �� �'" Character M t1Q9 d a thP��of�tom: a WatIK tile~AsplA- fi �• <br /> f SEPTIC TANK rJ iTYPf/ CapaeRll►:...-- -- No. ti r 3 JRj <br /> PKG,TREATMENT PLT,p ri MDhpoetiM~ s <br /> DI.tanoa to narset: Well ., Four>dlitlOn , PfO""00 <br /> '. LEACHING LINEfl Na.6 Lacy%of tinea Total <br /> :E fFILTER BED `O Distance to natnaar Fourrdatiarr Wad l � •�� <br /> SEEPAGE PITS 0 Depth Slee" Mrm4er xh �, <br /> SUMPS a obIW"to rarest: Well Famdatlao Properly Lkra ^--�— � � � �• <br /> DISPOSAL PONDS <br /> e' I hereby eLrPO that I have prepared tlaa an0licrian and that tha work will be done In a000rdW"With San.FOS"%oeunlfr ordl WWWW Stela 111WW <br /> d <br /> rule and laputstions of tits Sen.Io"uin Lova!HSahh District. ^ <br /> k" me HoW~or heart-- apam'a eipnature certifies the fofowl"t 1*1 cWWV that in the pertormanee of the work for food "partmlt is Iaatred,l dM net <br /> employ emir person In rm mw so to became subject to wakmsn•s comaenstdon taws of C.atMorraa."Conbaetar+e hlrYrp or strdcemlrSlollnB `• Y <br /> awoke the follovAnp:•• ,p N that in tM pew of Me work for wMeh oft permit IS WkW,I shall employ psartrene 01*d to wahine ft c on4oerdw "* 3 <br /> tkrn bK"of <br /> The 'all{xryyb � lYY�1O'ce W" <br /> -i u <br /> - f <br /> s �•t'lCLf/f"�t! f.•"tee [ ft <br /> ! FOR DEPAR NT USE ONLY a <br /> Application Accepted by ate A <br /> PM or 4nwi imsplon by <br /> D' rN e Snal Inepectlor by Dale <br /> eti <br /> Q ltipma!t;0lmmefltf: -I.-.�-a.s�•-=AL1 <br /> JL=1104it <br /> 66�7913693021 an ❑Tre[y <br /> cam•Rml,a6 copies to: Emripanow ai Health permllISsrvioas 161)1 E.Haeakon Ave.,P.O.Sox 2009. Stk:,CA 08201 :+ <br /> �I <br />