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IL - �� <br /> r A <br /> ! APPLiO $ N FOR FIER vMIT <br /> SAN J.OAHAZE—CONa 9N f.00AR.LFi^4E1�L r�9�/+-�-,3l�T�`1�CT <br /> IA 1601 E. AVE., S•€OCK 1 Vltl,r.CA <br /> Telephone (2D9) 4W-Ml' . . <br /> PERMIT EXPIRES I YEAR FROhrj DAYE WSUED <br /> (Complete in r riplicate) <br /> ,i Appiicatiat is hereby made to tho San Joaquin Locai Health District for a permit to construct:and/or install tNe worn iters n descei:asd.TtsL3 T.�pfiefitfDrk is + 4 <br /> rriada in crrmptiarca with San Joaquin County O dImnce No.M9 for cawage or No.1&2 for wat€/pu:rp rand tho Rulos and ROGuWticm af,tirs Jolaquin <br /> a <br /> Local Health District. <br /> L � jq <br /> sob Addrass <br /> �K <br /> € � [� V S phone <br /> Owner Nance .�, — AddroGa .A�''" a: '� ,y,a-• a ';. tf R..'•.} <br /> ,. p. d License �.W �, Phone <br /> contractor's Name . : <br /> TYPE OF WELL/PUMP: N LL'REPLACEf�lEl�1f n 'DESTRUCTION ❑ +•r r '• ' <br /> € i PUA1it�INSTALLAZtO7 »SYSYE°Vl AFPAI ❑ Y `j At�iE61 <br /> I , <br /> DISTANCE TO NE/+ ES is SEPTIC TANK 4_.ef1L+' SEFftlCr� LihfES DISPOSAL i:LF1 a - PRf7i+ �IS1€E T: <br /> FOUNDATION '� lmCiP.iCli�'iili+E 1 El.L :"OYIiERktrdCL P� rs-!SUMPS <br /> �� .— r <br /> i�'i'EN03GD USE �'r�E OF WELL PR+JBLg_w��AFEA., CCBf�S7r�UCiIdJS�^oPfC�FCs4 e©P3 , r <br /> _ a..� f3fa bf Mfg CttsFea@i ' "� r ' moi. <br /> d lnGtastriaf — vpon Bottom 0 Morltecas D38:o!Wtatf E.x�av�8ort »-� �'1* <br /> of CslrA" ! "- Sillr�teos s' r <br /> tvr l Priva4a ❑ Grzt,4 Park YPa s <br /> ❑P:sb€Ir ❑CrrfEer, ❑ Daslta Doth of Grcu4 sw v -� of(ietAut ra <br /> ry A a ao c.EYa tPs i 7 ^^>r rr+ clsro Sam]Ins'it;ltod Isy-- <br /> I ❑ iniws on: --APP P �•,� <br /> Rmpslr Vl1or€:Donor a Typo of Pump $' 5te.s`1Alo7k Dong F w <br /> Well Dogrucdon u W61 Diamalar 5a iia M�A.awrial itep <br /> Death _ ®. �� <br /> , �__...,m�s....a..z <br /> Y? Or SEfai€C WORK: N:-W N ALL4TIGN❑ R,''PAiR/BtDD€7 N f� tpESYEfiUCi1 C] (3�o t�a+titr X1 4 i•+'xini"M If puhlc=vwr to <br /> r`!]$y � '-sv�;aillo t�ithirs�3 4e+►t}. , _ :g r� ,r <br /> €r.�.cftetion'vgi uarvo: Raskience._ Gorrmsra c i Otfter' ,.s ' y Yt m <br /> f NumWr o!€Mng units: Numbor of bedroDms, t ter° k• 1 � 5 <br /> Citar,tcw of coil to a ftrb of 3 fit: 4�l�l ar <br /> �SEPTS«TANK ❑ Tyb8AWg C&paukty �!4�aCsa�Ratta 4 <br /> r }' iVi O!Dispai �_ f <br /> PKG.TRIS I Mr I PLT.❑ �3t <br /> w�. Distance to nearest: e Wolf lcoundation Prop3lYyLirro Mk a w <br /> LEACHING LINE <br /> ❑ No.a Length of lines '{ ' YTotmi M3ngthl <br /> w P ` <br /> �FiI.YEFi OED <br /> ❑ Distance to naaroat , W%�j ' Poundal bn PeopbrW Ll� <br /> "r <br /> SEEPAGE Pri S ❑ GOP-,h - Siu] <br /> SUMPS x! G fiat.neo to reesro3sat' Weil F-oundetion <br /> t Itorc�*/r tiSy tivat I i>ave pc�parod tt s as, lieation anal tfiat Cale work w itl dont?in'ecordanou vaith Gan Joaquin county+ordinanaxo,sta"e tswta"and <br /> nsFr3 tnd eu3ta;irrr c r the Son J�,s�u:n Lorof tfttPa D{s2r<.t , <br /> f: Hur,tp ri-,�t+sr cer licans,:d a�nt'a aigrsatarr9�rrifltac t'h&!ni€rnsv3rg:"i acei34y that in file perfomteneaa of tha work fol:v�icF+this F"rmk is'r,�uu� I sfsafl,ntat <br /> arrp4oy a=+;pac ora fn eaucit rrsanrwr ea tri x� repjEs t to ylwr rnJ n'c compe�sEttlar laws a'?C.Bt+fOm¢E.'.Conuactoes hiring ar ruka cs�n2recr+ng trgstature 3 <br /> c rbf s i3 a rsts3itwi r:"i corxit�i that in ttw porPormsnccs Gf 4ha o Ifs"Or vR+iCy this per 3i ie i zued,I ShO rarrii2Soy ns sub to wrorkmre►s cornPo <br /> 1 r` <br /> tion firsh�Of Cs€ifornia." '., <br /> Mite ctY3ficedn2 nail Oar �Eag�rtti We drrvving on reveres 1��,�„_,� <br /> r <br /> Signed X_ � r � OOtA <br /> FDR Df-PARTMENT USE ONW <br /> Applicaftri Acmied by M A <br /> fit or Grout Inepoction by <br /> �" Dare F1nal Irspactaon,by Oitt! <br /> Additional Commonts. <br /> ❑ Stk 4M-CMI (j odi Si�'=i Cl€WGn4mt� 79Q>i ❑Trary <br /> Applicant-Rawrn all copies to: Environmental Health Pom*/SoNfo�i 7 E. Hakssi9on'Avo P.O. box 9 Stk 'CA 8�a21it; r� s 4 �� <br /> y •k 3` �4 <br /> p� FEE CASH RGCEIV£D CY DATE i PcRMkT PiP.`'' <br /> { <br /> INFO <br /> AMOUNT DUE AMOUNT REWT77ED _ <br /> r; _s <br />