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i <br /> i <br /> COPY <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT" <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091466-6781 <br /> PERMIT EXPIRES f YEAR FpOM_bATE I8$UED <br /> 1CDmplete In Triplicate? <br /> APflication is t'"If?hv made to the San Joaquin local Health Okiltici for a pttrnfil toeenetruc;endfer hts;aq fhg pp tterehi <br /> mads in Healcomth <br /> uaneo with Sen,looquin County Ordinartce No.649 tot W-aW of No, 1862 fogy watllpum�t and the Ruin tUtd gulallbed,Ttt4 }} <br /> Local Flealttt Gisr.itt. �IatiPr4 0#tM Sm,m � <br /> Job Address <br /> -7- - <br /> G € ci Lot Sias PM <br /> Owner's Name <br /> Eb ;� ;;. <br /> E <br /> Contractor ,,dtdsa' y ' ,' e -a" <br /> TYPE_OF WL.L/PU P: NEW WELL Q' . .y �yC <br /> -'--- vvt L REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION © 8Y$TftAi1 pEPAIR 8 D <br /> 1 r DISTANCE TO NEAREST: SEPTIC TANK �_ gR LINES OTHER d <br /> FOUNDATION " ^'�-�-^- RISP09AL FLD,_„„� pRep, LINE <br /> _ --- _ AGRICULTURE 1HELE OTHER W1 LL.. . <br /> INTENDED USE TYPE OF WELL PR09LEMARi' CONRTRuthoiv,SPkIPICAt"s PI7SlSUMItS <br /> n Industrial <br /> E:; Open Bottom (�Ma� „row'. o ,of <br /> ❑Domestic/Private I:l Gravel Pack a tCaVat <br /> Dia: W!M ^0 <br /> t"I Ptdit I'l Other f-t DatteYpb of S tioiti '� . <br /> I I hnigalion A bwh Of Gt�out S <br /> --- <br /> Approx. Depth I I Emtam $tttfaci SIHf titltaAa� Tvrda of dicot,..._ <br /> Repair Work Done 0 Type of Pump -- � - <br /> Well Destruction 1-1Well Diemetar 'Stl1a W"6004 <br /> --�--�-�---- ='�I+�i Mrt4leridl titin 19D 3„ •" <br /> Depth k 'OF AIR" <br /> t ;' <br /> V7 PF' SEPTIC WORK: MEW INSTALLATION I I REPAI 1lIDDITfDN, <br /> 2 , OESTRUC i f <br /> V. .. � <br /> f" �t1 p�t�s�Im if pubflC 01661 i5 <br /> nsttiNatlon wR aerva: Residence <br /> S k riiithin pOp fort•1 , <br /> d * y <br /> NumbAr of q»ng units: Numbw of beekpotYii ,@«'.. ::.,, i• ' b .n,m" x a r. <br /> Ch*WW of 000 to a depth of 3 feet: a " <br /> SEPTIC TAFMmW " <br /> t PICf3. ❑ Type/Mag c# w Waf#r , 1.F _, x . _• ,�t: �. <br /> TREATMENT PLT.D # IIkD.4plty 9 <br /> Distance t0 'h ' , 15 r x a�filtod <br /> rrelfntn: WaH flArl LL <br /> - <br /> LE/1CNINt3 LINE n NO. ik Length of Nnea s � <br /> FILTER BED 0 Distance to oaarpt: ti Tbtid fingthltilFa <br /> 'Waft" hf011`0141 Lbtlt= s - <br /> S£EPAGsE Pl i I Depth <br /> U Sip Number <br /> I i Distenco 10 nsarm: yy�j � <br /> f DISPOSAL PONDS [.7 rFoundatlwi' r <br /> A'opd+tY <br /> } Iz <br /> I hereby cOrlifY that I have McP;.trd this a <br /> i rules and r�ulstions of the San J pplication*Ad!frit th!vM*Will Ito dohs In accord"" <br /> tforrti Ptwrtsr or ti0ft of Darwin Local H*atth Diktrlot cord""wkh Sats Joaquin cegi►ty <br /> agent's signature ca:tifiea the t •a taws ` <br /> arra <br /> r +nY pMaon In such manner as 10! ° 8•"I tls,t iit tha Psrforfnarnae of the' <br /> avi7rlt far tY1rlClt�tld! ` e .,,, r' . <br /> Call t to tokwW g:"I certify that in the padur o m WOrk I6rawh � "C tl�t iei'a!il/Ilp I1MrNt!!fgllf�d,"1 ahaii tqk <br /> Mar 4twa of California." p&"r It is k+uud.IstrN rBnatum <br /> i The ippic"t t f requi a F �Y Owltaft fgrbjset to Wolttttatt s am"pensa. <br /> pectigtta. <br /> Sighed Title: t . s <br /> DBPAIITAk40ff UBIE O&LY ; <br /> AppGcatlon.ker:epted by � � _ -"•"t ,.- . <br /> Pit Of Grout I —. <br /> Data ' <br /> rrafrectlon by t Arta <br /> r. <br /> Rita <br /> Additional Comments: . 0 <br /> 8tk ..,ww. a. <br /> 468 181 C] Lodi 369-3821 ❑Manters ffi7Y7101 ' <br /> AOpNtant•Return&N eopiea to: Environmental Health Pitrntlt/ T^py ' "+ •"F <br /> 8mvioea tBp1 E.Hf ieltbti AW•P.O."float om..CA Wet <br /> FEE <br /> INFO VNT DUE' AMCUtttTIItMITTEp SHpi?CEIVEDev tlA1E <br /> 70.fl� !LY <br /> Ex Noe • r - <br /> a <br />