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r R <br /> I <br /> I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.. STOCKTON, CA <br /> Telephone (209) 466 6781 <br /> PERMIT EXPIRES 1 YEAR-FROM-DATE ISSUED <br /> (Complete in Tr'pl'cate) <br /> :.hDla ahnn s h.•.vhv nearfe to tt•r San Jnagrnn LM'aI//.e'•n I1'�1rrt for a lvn`.r t..rn..atrur t an.t'r...+•.•ae tat r.wL�«w.n rlwtc nhed TMs applrtatrnr,n <br /> m.•dr'n n,••rt•ha.xr wnh pian LwM,nn r,.,nry 0"I .•hr S1?yrf w sf11•wagn n.H•• t.l.;I�r.�r9 I+,n�r.ant th..R,drt&•d Rrn.tatr,,ns 01 the San JoarPnn <br /> lr•r al Nra„h Il•V•.1���.� <br /> Jnh Address�V}'f'JtJ f�• V �if'1i�. - - - - -. ..___ Gt. _.�LLi,-... Int S•M PM <br /> IT1,r.,e•s Nsmw iamb +•W G _ 4A.Fns .. ._._ Ptw•na __.___-_._.__... � . <br /> V� I '! 4/nr/w L., 11 3 77fzJ F113�s3� <br /> Conti tctoi I W�i7. 1 _. —-- <br /> TYPE OF WELLrPUMP NEW WELL K WELL KEPI Af.t'-It':I OESTRUCitON . <br /> PLAIP INSTALLATION X SYSTF•.t RFL'AIH OTHER <br /> DISTANCE TO NEAREST SEPTIC TANK _ .__-_ SFWEP LINES _. DISPOSAL FLD PROP 114C <br /> FOUNDATION _ _ AGRICULTURF WELL OTHip WELL _ Pi'S SU%RPS <br /> INTENDED USE TYPE OF WEtt PROMFILt AAFA CONSTRUCTION SPECIFICATIONS Jr <br /> e i <br /> InA ntfral X Open Rotttwh Ma•,N.a Uv of fru F..aver vn" b' .. Du of W0,11CR"'(1 �. <br /> ?(Dorn'strC I Private roavM PAA Trx:v Tv[»of Ca..M7 �� ` 5p.crfwalww,s ./ ' <br /> i <br /> V:rHrc D"' Datta D.•pth of'..chit Srat Tvpe ref Grm•t <br /> - (�' 9 <br /> eren Ntwvt WrAprynw Dpnh E.Mtrrn S..•/are�$v..l,�+ra'�w.!M _ _ _ _-_ �•+ <br /> Nrpwa VJM► Done Tvpw of Pu-P <br /> W-0 Oesptrctron Wes D,~w Sr.r►•,u May.al sh.I 'it I ( S <br /> Fa <br /> n__.% _ __ ter Matr.al:Iter•.�r. <br /> I FIR OF SEPTI(-WORK �•rN1 WINS1Al t A IhtN HI PA,N A1tO•ttt rr� I.I�.!•,, h.,4 �M r M rich• / ,'^t d p..h•.�ss.r.�.n .. <br /> hwtafNtwwe v.N s«ve Restrlenco •_ Cnr.w.•e.c•sl Ot•.'. e+ <br /> Mornben of hvwrg units --- Nu of Ite,trorw••t r <br /> Character M sod to a dn"h rd J/eof --._.. W.ee«tvBM rsfPth <br /> SEPTIC TANK t 1 Tt,pe'Moo f.•n.•••. No Ccwr,parttttents -- --.-------'._- <br /> PKG. TREATMENT MT. .1 <br /> MerMwt of p•tMnaf _ <br /> Dtnance to ren t Wee ForwvLf.-n t'mtw.dv twee <br /> LEACHING LINE I' No 1 ter%Wh d - Tnttt 1•.Mph wre _ - - <br /> FlLTER BED (1 Dwstarwe tit twearost W«+t c rrrrttt+n f•ropnty law _ 1 <br /> SEEPAGE RTS i I Oepfh _._ _ --- - _S'ee Nrwnlee. _ <br /> I {t•,.r,.taFM F4tww tv I ww <br /> SUMPS I D.stanee to rwwwst Water <br /> DISPOSAL PONDS 1` <br /> I hembv earhfY that 1 Neve Prn%MWW tats appitcat•on ar•d that on work rat he Is,~.n r cwd0%a worth San Joartrrwe Corrr•W wMWKY'S.state la,ue, arnf Ir . <br /> nA ws and""tro w of one San Jorttan Local Heaton Dritr•ct <br /> Horn owner or heensed agent's NVIefuro ewwf•I+s the foaowwW "rert•ry that..tt.w t�.•nrrnary o ref rine"gt.Inn wlwc}e fats D«r't,r w.as•otd.1{haT not <br /> &'wont,"person ern such rrrsnner as to lrcortta subwct In w tirnan t c.w•rt•.nto—tt w.era(:Aid"'ry Crwtfra[tM'e Mwrp d t•A cr •acttnp uQnmA <br /> cerf•Iw one foeovwe0 -I centro,ort ro rho prrf•trmrne of Tho rHJ.h on,•Much fat P«r.-.t n nv r+ 1 ws orro4ry P«som fu+yct M wMsrnar:s cn-ven+a <br /> frtte base of C464W O <br /> I/r �rrr ��{fur r w`Isrr•eaM Cronyleta.Ya►r.y rtn� f/ lel <br /> gn«f T.te Q� Oatir <br /> S - <br /> 7PA{zu[NT USE ONLY <br /> Apphraoon Accepted ht, <br /> _ 1 <br /> P,t M fEtouL lnspertron ht, Te--J in o �����G.I F—I I.s.-t.•n Pr2 <br /> / FF! <br /> Adddrone0 Cornrmnts: - <br /> I : Stk AM 6711 C I Lod• 7114 7621 - C menteca 127 7104--- 1- T rery RTS 5715 �\ <br /> APphcattt Return AN cttlt•ee to- EnvwortrrweIgo Heehh P«ww-Serv.ces 10101 F Natethw.A%*. P O Flow 2TI Mf. Sib CA gS,+01 <br /> rU'f 0.i w <br /> -__ 0a rt nw{,hr ♦:�, <br /> 4 AMOUVt Mrf 1- ,• � <br /> 1 l k' <br />