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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209)468-0781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br />,pplicetic.r is hareby,made to the San Joaquin Local Health District for a parmlt to co newt andla Install ttu work"rain daecrroad. This zpp icanon e <br /> .ri.n conpEanca wM.San Joaquin County Orlinance No.698 for 0 IQ or No.1862 for well/putrlp WA the Rules and Rapulatbn PI tel Gen Joaquin <br /> o; l Health DebkI. <br /> i � � <br /> lob Addy S7,09 F /r�i� eW _ M Coity ` .E�!! Lot Sia <br />)wnei a tI lllCrfJee //J4haifesl�/L t�Jotl,Addren —__S.'7OF�._�3s�+e+—L`_._ Morita �..3/�Q?/i� <br /> ontractofs Name�i ? Icense No. n r PMrw-Ar-- M.4y <br /> HYPE OF WELLlPUMP: NEW WELL V,' WELL REPLACEMENT a DESTRUCTION 0, <br /> PUMP INSTALLATION M, SYSTEM REPAIR Jk OTHER-C. <br /> DISTANCE TO NEAREST: SEFT)C TANK _ SEWER LINES DISPOSAL FLO.._._.-_ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _._ OTHER WELL_. 1 PITWSLiMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Irduatrlel ❑Op Bo"wn ❑Mantac► Dia.of Wal ExcaAWn I De. of Well Casing <br /> Ile Do,rastk:/PrMte ❑ Gravel Pack C Tracy Typa of CseM- " SpecMkatens <br /> 7 Public ❑ Other r- Delta Depth of Dread Seal Type of Grout_.-____ <br /> 7 uriganon _Ap.`m.. C'p'h Cl E e m Surface Sall 'Irl- <br /> Repair <br /> Ir __Repair Work Done ❑ Type of Pump AA _ M.P._4.t�L___ Stale Work none .. <br /> Nell Destnw*m ❑ Well Dlenrter -JL�— Sealing Matadsl flop TO') <br /> Depth_ /.sem Filler Material Igalow 60') -.- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIAODITION ❑ DESTRUCTION 0 (No septic systwn pwmined K public newer a <br /> avail"within 2f10 feat.) <br /> Instalstion w41 servs: Residence- Cornmertiel __ DOW- <br /> Number <br /> OW_Number of ung units:_ Number of bedrooms <br /> Clmrectar of sol to a dWM M 3 bat:_ _ ---Wstw table depth__._._____ _- { 't <br /> SEPTIC TANK ❑ TypelMlg _ __. Capatlty No. Cornpertmerns _____.-_ <br /> PKG. TREATMENT PLT.❑ MnIhM of DNpoMI <br /> Distance to nearest: Wen Foudation Papeny Lire <br /> LEACHING LINE ❑ No.a Length of Wm __—__.__TotY WVthlala_ --- --.-_ <br /> FILTER BED ❑ Dkmnw to rwnet: Weal-_ Foundation Property Liu <br />,FEPAUE PITS ❑ Depth SLs_.____ µanger <br /> SUMPS ❑ Distance to nsenw: Well Foundation Pmp"Liu_ <br /> DISPOSAL PONDS ❑ <br /> I heratry unity dw I herw,peered the application and the,the work wR be done in acoordavoe with Ben Joaquin toady ddYnnees.stab laws, and <br />,ulas and regulations of the San Joaquin Local Heats District. ' <br /> Homs owner,or licensed ager,t's$"lure cerdlee tel foarnvina: •I certify that in tel perfamanw of that work for which 0*pamit Is Issued.I shall rot <br /> nRlplay arty parson kit ahrai,nwiwr w b flaOarrM eublec,to wprAmari a C'a•••Wrleatlan lana N C��•.,Canlrwtor'e Ihaahg p a1lAsontaatkh4 YprhaNM <br /> certiRw�'he 1oly vMq:•, cergfy Mut len tel perform o of tel work for which the pemth la Iastlad,I aha amgoy peraoM aublsst tawprkmr,'e comperwr <br /> tion Ione d CYNarY <br /> The appEard moat r h action. Complete drawing on <br /> Signed f _ TIM: l «1% - - Dab: <br /> rat' <br /> FORARTMENT U44 ONLY 'M <br /> Application Accepted Dale �raa j <br /> pit or Grout lnapactbn , 1 <br /> eta Failte)kspetdon by <br /> 1 Rtk sMd7E1 Additional COMMICTIS: <br /> 11 Lam 30e3821 n Marasce M7104 ❑Tansy 11"M <br /> Aapnccanl . AM.-an eupkr to: Ernion,ne..ul Huhn Permit/fferw 1401 a.Hsaalbn Aw.. P.O. Ilse 4000, Still.,CA"M 1 ,r_ <br /> 't <br /> FEE AMWNT DU[ AMOUNT aEMRTED Rflt:eVlO 4Y DATE PlealrT"ND.. 1'; <br /> INFO <br /> 1i _ 1s9 <br /> .,nn, rano, 3 s _ <br />