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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1901 E HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 498-8781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> cation Is hereby <br /> (COMPlate in Triplicate) <br /> � n with San JoMt*County ONhrfc•No.S6 fo, • w to 19afwCmwvuYA lw MW tlr.writ and pl Ea.aiL.e.Thb appb=*n Y <br /> Locel Health OMwi.r. aawepa a No.18R fortree/pump and the RUIp and <br /> Repuwnorw of tlr San Jogs, <br /> Joe Ada ar 2 T7/ Z- !.riyf/ /10 .�'� <br /> City �'!�l9 Lw She PM <br /> ownwr'a horn���f �1'�Td Adcbmas �9�1F p�„a 9F2—Sa"9 <br /> Cormactoes Nartr20604/ Phone y ?6i6 <br /> TYPE OF waupUMP; NEW WELL O WELL REPLACEMENT .^, DESTRUCTION 0 <br /> PUMP INSTALLA71ON 0 SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. I.M. <br /> i FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENC£D USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C tnducatat —� 0 Open Bottom 0 Martwo Dia.of Well Excentbn Die.o!Wen Caving f <br /> •Dornan./Private 0 Grew Pack 0 Tracy TYPa of Cadnp Bpec9autemw <br /> C. Public a Other 0 Delta O+pth of Grout SOW TWO of GMA <br /> U I•+ipatlon _Approx.Depth 0 EwWn Surface SW 1 'by —_ <br /> Rep*Work Done 0 Type of Poem—H.P.— - Stas Work Done <br /> Wel Deeb Xwn R Wal DW Now - - Sadrp Matw►e twp wl <br /> i Depth Filter M•srW 16e10w SM <br /> TYPE CP SEPTIC K: NEW INSTALLATION REPAIR/ADDITION L, DESTRU (NOteptb eye",P"4md it PYt:mom Is T <br /> _ _ aw4da wtthn 300 Net.) ••/ <br /> Irwulaeort ori eaM: R.W"- Ca wwrcw'G'Othw ., e <br /> Numbw of"tuts: ' .Number of t <br /> Clwoclw of toll to a depth of 9��]ew Www I"fid' �} <br /> SEPTIC TANK ypQMfgy s'Tf t%aPacitY No.Conipwbnarft Z A <br /> PKG.TREATMENT PLT.0 ' ) Method of DiaptwN <br /> E WW.to rwrwt: Wait,�..._ Foundation ftPwty Lk" Vz! <br /> LEACHING LINE No. a lwgm of Wm �� Tow lanplh <br /> FILTER BED 0 Dssnee to neeroar: WIN jrd7 Founded.". 'O Hoperty Line <br /> SEf)AOE PETS 0 Depth Sha Nix110at. 1eO <br /> SUMPS O Dtetama to no~: Wan PwmMlon Propwty LAw <br /> DISPOSAL PONDS 0 <br /> 1 hereby aedfy*A t hew psple dtla•PPpowiwi VA gm on work wit M done in aoeofdenw wIM San Jowprn county orwwrw►L e•ne.Wa,ted <br /> rutaa and 1p.. .' of Mia ON im*Led He"DYlnbt. <br /> Hones avow or band ag Ws dprmett•e Oerllllea IM kbwklp:1-1 owWy that In on pe kmwtoe of the work for ttftkh Ulla Pamir M"ad,1 aI+N net <br /> ompioy wry poem n tach mwnw r»D•oorrw tub)tot fo vorkmen'e oonppwawlo t More em Da11omM•"0010 V POW <br /> Wa hknp or wscaitreewq atP.etuw <br /> cordite to!,a, :"I rpt n 1M pwtwmwiw of the volt for rRYM thM DwmK le lewsd.1 anM enObY Pwawr•/b(wrt b wMnrn a opnpw+ <br />!11 do"Wes Or C WD"dL•, <br /> The•pabown"ales 7%-2drewnp W reveres side. <br /> I S TIM: <br /> PDR DEPAItTM 9N'WeLY <br /> l� <br />:. AppaeeOar Accepted try q�6-0 S <br /> t 9 • <br />�3 Pk or Gran hnpecdon L mak...? .a.11A inM kwpw:tlon by <br /> Additional Comrwnc t oa �- C/�E�1,A 21 --.•• <br /> O Stk af1667S1 ❑Lodi 3epSS21 ❑Mensa fO171b1 O Tracy <br /> Appaown"Ranxn at cogMe to:}6wUonLnerxal HeNdf 1BDt E.If{1Ntot�l'i(E. P.O.Sar IDOS• <br /> I' DIA AMOUNT UNT= xy,R�l `J•A/h�..7 �+��.FL, PMkeY NO. <br /> CIIINIED <br />.: ys,. nb 9-i�->tr. Ps des <br /> .01.ar►w nor. <..«.. . .: ._. . ---.,'.. <br />