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.� �-wit+r+r � +r:. ,�...:. � _.. . . .,.- w•3:. :�. vrr«Yav»+;jP. wv Su <br /> a QM <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209)466.6781 <br /> - PERMIT °XPIRES 1 YEAR FROM DATE ISSUED ,y +� [ <br /> (Complete in Triplicste) <br /> AgYir>.dpn is hereby nude to the San Joaquin Local HecIM D'Mnitt for a permit to cpruttuet end/a-stall fin rrprk Iherakt dntaPaM:� Y <br /> rim a in compliance with San Joaquin County Ordinance Ho.W for towage or No.low for well/pump and the Rulsa and Rogabdoru efl$i'SM' - ,t <br /> Loral Heahh District. <br /> city�c�4fato <br /> Job Address La$im <br /> Owrart Name -� 1�m m6 s Address - SCy'Kyj- .. . - Plwne eye <br /> .;._ ...- ! Address - . <br /> Contracts ` Ru��d� 1/ Lltense N42wo,Ph" ` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> ' ---' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ -- ' OTNd1 ❑ ' <br /> DISTANCE TO NEAREST SEPTIC TANK _ SEWER LINES f' DISPOSAL FLD._ PROP. LINE <br /> IJNDATION AGRICULTURE.WELL _ OTHER WELL— <br /> INTENDED <br /> ELLINTENDED USE `'tYPE,OF WELL ^T PROBLEM AREA' CONSTRUCTION SPECIFICATIONS <br /> ..'" A„❑Industr{el `- ; b'op.rBotbm =❑Manteca ::Die.of Wall Excavation Dis of Wag Cadre 't!+� i <br /> fig lclPrivate . '. ❑Gravel Pack ❑Tr%v Type of Cs.ing_ 5petiRcajbru 3t..'" `' <br /> -} 'x-,,.11 Pu6Iie-: _. .'..❑Ot1Ler__._s u__.,_❑. _ .. __ � •u+;!#.I s� .'t. <br /> { Depth of Grout Seel Typo car Grad <br /> Irtigotion y ,_Alpproi:DepM ❑Eastern—._..- Surface Seal Installed by <br /> Rgaak Work Done-'- ❑ Type of Pump I ' - �. H.P. f State Work Done ✓-t <br /> ...Wall Dnehv^tgn ❑" Well Diameter . . . <br /> h.:S"Ung Material(top 50'1 <br /> y`4• 'r w _ Depth! Filer Material( 51 <br /> s!'v TYPE OF SEPTIC WORK: NLW,INSTAL#ATION❑ REPAIR/AD0DESTRUCTION O (No septic system pol MI I pubes tawe[,Is <br /> availablewithin200feet.) _,,;V-­ <br /> ;V .. <br /> Imbllation wnif serve \96sderf e, �Cphirtlerefel= Other 7/ .• I `a�'.. <br /> ' .Number of 6veg tmRa:� tfurnlw of Wdmonu �' i t <br /> `t,� - Clwrectw of sell to a depth of 3'feet: �"n'A -L60 IM i . ._ .. _ Water <br /> SEPTIC TANK ❑ Type%Mlg Capacity No.Cm+panmenn <br /> PIG. iREATMEM PLT.[I Method of D'umW � o, <br /> J) "of�'7 _ . <br /> .y.-----Ditterke to,naaest. Wall .-53 FnunJation�I_ I'mooty Line�.y_,_ f �.` . <br /> J' LEACHING UNE ' ❑ W. 8 Liiitpth of Wien- ( � Rn Tool Wvffi/si[s 1 <br /> f'. <br /> FILTER BED ❑ na <br /> f dt+ce:to newest. 'WON O— FaundeNon.. Property Line tin <br /> SEEPAGE PRS -'.❑ Depth._. _ - Sue <br /> .SUMPS ,� ,.. ❑ Di tance to neeralt:, Well - - Foundation +Prop6M Line 'Sr <br /> v. ' a DISPOSAL PONDS ❑ <br /> A hembY cw*that I htwe prepared this application and that the work will be done in accordence with Sin J 'r`d <br /> Mee and rOWLedp.u_of the San Joaquin Local Health Dlstntt. papain coh;rrq'ordkbncn,stab laws"'and J <br /> Hann owner tw Immo agent's slgnam­e eertifua the following:-1 car*that in the pwfCrrnarxa of the wale for whi rltlla pwtttlt Is'",.I shall hwt t�}rft <br /> %'anploy any Pel}gp in.such manrta[as.to becane subject.mworkinan't compmmtbn.law,of CaWorrjs --Conaacb/a hit rp a sttbcontruth <br /> 601rt8ee the fotow hV:'1 certify that in the perforinence of the work for which this re a d Ynred,1 shale employ person tetbpot to s+orkrtbn•r:otrlperns.'+^I <br /> cath <br /> ` <br /> t r a <br /> g <br /> The <br /> apd am m qlcaN for tip required kulNctlo u. Complete dmv ng on olds. i Y 1 C <br /> 3 Signer,X � 1lr� Title: D <br /> °�"° � n. <br /> q [ <br /> - _ `N�f�c <br /> R DEPARTMEMY <br /> t._;BE ONLY <br /> it <br /> y' Apolkxtton Accepted by <br /> Deb <br /> Pn or,rrnr,'napec[ion by Ihtb' final lMpsetbn by Dab <br /> Acldo nal Commenta: <br /> rwev. 8364M <br /> t P - A Slx 466-678l RaTUt co❑P4a m�nV1100madal H th PaMt SWVIIM 1801 E.HTneton AA". P.O. 2008 Slit.-:CA 86201+ a <br /> Applisnt. - Retum ell <br /> INFO -AMOl1NT DUE""' AMDUNT REMRTEC CASH RECETJED 9y' <br /> NO 1 °} <br /> PlERMn r wr <br /> u• l/ <br /> N <br /> Jn-"++a'%+•..Hdg�' twv:.rw.,arcus:�:F�.S+Fc.ei.id[euw�wKii+'.91tis^.ti4hifA . <br /> yaV, <br />