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<br /> APPLICATION FOR PERMIT
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICE
<br /> 1601 E. HAZELTON AVE., STOCKTON, CA
<br /> Telephone (209) 466.6781
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
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<br /> - (Coplete in TI'Iplicalel pal
<br /> Ap{erea4on n lamhy merle rn Ita San Jcanurn Local Heelth 01se1,11 for a MI'V-1 to Cnranuct and/or,.stall thew . .• r r An<r t•+.. Tlm:
<br /> alb M C:+m.....nrnwilh$nn JrlaVN' ........OrllrnalflN Nrr tq'1101 anw'a(la Or N•1 llMrl lVl wxlllpump ar+rl lh.+lt,.... .r•,I11,•11,,. . •ll it
<br /> loan k1.1114 nrrlrrct r p
<br /> Jab Ad.l.ess _zTTs}lCf't2 �- :, x.. _ PM .
<br /> Omw.N1. F Atlrlrr.rs
<br /> WALTtlkI,.L. _ C_L� {tbkr.en
<br /> Convar,Im .- - - -- —
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<br /> TYPEOf WELL,PUMP NEW WEtL WELL REFI Af.F L.t L'a r . DFS rH .C:e'v
<br /> ,il,.l is ..
<br /> PUMP tNSTAt CAi10N SYGTEM Nr'AIR 1
<br /> DISTANCE TO NEARE51. SEPTIC TANK SEWER LINES _-- _. DISPOSAL FI 1: - PRG: LING
<br /> - - f0UN0_1;ON _. AGRICULTURE WELL __ OTHER WEII _ PITS15Uld PS —
<br /> INT EN0LOUSE - .-TYPE CIE WEtL PRURt.EM AREA CONSTRUL I10N SPECIFlCA110n,
<br /> IndavT Ul Owr•Rntwm Manle.a a of WU1 I cavae..__ - Ou.al`Holl Cas,ng
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<br /> r Uorm•,urt•nratc GrsvW Pars ". Tr:+cY Type of Carr+.l_ .__.._—__ -. ..__ Specifications
<br /> ' : R,ULT T Cn Mr 1 Onll. 13611111 al G1,,I S6al _'__----__—_- IYpe pl Gm., -
<br /> -bn;M b.+,: A,,,a D,n:1h : Eavenl S...lace Se.. T stalled by
<br /> Repan Wed D.rnu :1 T,.oI Pump _ _. Y P._._._ _ ____ $lata Wms Done -
<br /> WHI Dev;mction .: We11 Drametel _.._ S"!,nq Mabnal 14¢r`t'I __—__ __-- —- -- ---
<br /> Depth _ __ _I Eakr Material
<br /> TYPL Os SLPTIL: WORK NEW INS1IALLATION ti IILPAIR•40OI11ON I�IIIK11ON (N•Irlsl t•'°wm..2(101661 Imf R pubbc x••., n
<br /> mslanauon w 11 serve: Re &—,,ca `'.' C6Tmn•cra
<br /> Numb:,of amlq umes ._ Numbm of(^t�xdrwmsn__�___
<br /> Cnuapel al sou la a deem of l fir. _.-/-1�"'f�� We1mM,ab1e depth
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<br /> SEPTIC TANK f] 1,0Mtp _L_.ci ete,
<br /> Nc r- .--- C......... '-�[ - No Cor•narrmenls '
<br /> PKG.TPEATMf Nt PLT.: : Y --
<br /> Dleune.fo...east WMI _7 F.vM,tcn _/. ___ Prolenly Lb.e
<br /> LEACHING LINE � oo &C.µ111 Ilroa .1J -
<br /> FILTER BED is Das.. m.xww Well �Q-S_ Founda r n ..��. P c•n LI._LQ --�
<br /> SEEPAGE MTS ,1115-wi __. �. T-.Sua y� _ ._ Number
<br /> SUMPS t I Unlancv m rwmest WNI 1 pQ� Foundel r _�
<br /> I hereby Cenrly Thal I ham.P,eWrW 111,s aPpl.cabon and that 1116 wed wdl be d.1, Tn accordance w0h Sun Joa•,,,,n,...•sa'r n:d:nai+o,..
<br /> M05 ant:bgu a(mna of tha San Jc,4.1m Local health Dalen _ -
<br /> Home owrwr rn I¢nnvW.66.1'6 uV^aMe o.n j.s tnN IWow.rp *1 Ir.4V that 1n Ihn PNrfurmenco ul tPe..• r Iv wn uh m s pe eel s
<br /> .,.ploy any m,.m such ma(%s ,ea Io become wbact W w0""'t s ar'penwoun Mws of Cello a r.�r rn.lni s M1nmg m wbcont'a m •.F-
<br /> c.hTbsthe foeowanpl ety Ihnl w,tM \do,mnnca of me wort la N.hTch m s t ,mit is ib ea sR 11 a r,•v oerwna supptt m wodrtvn a .oT
<br /> emn bws Yl^`fo.nm.
<br /> TM,xpPlYxnt a Iw a ./omp�l a drawing a u s. /•
<br /> STPrad ^J^�� nena'jLtb. L__ __. Date:
<br /> F EPARTMENT USE ONLY
<br /> 4:olsation Accepltld IV _ Si.aA- DataA�l. 1
<br /> __ Data Final Inapncdoe 6Y----_ n Uma
<br /> Pe a Gr,m Inapeuior,by _..__ r--
<br /> ,fditbnal DOmnVnts: _...___._J_-A-a-x^-" '�•'--����- ., ' / f;c.
<br /> I -Sp 4656781 C LWi 3693621 O MambGl 8277101 0 TmcY 6'f85 —
<br /> Applicant Rewrn all eo1:65 to:Eov.,oeloamat Health P.mvt/Senmes Ifi01 E. Hnaallnn Av..,P.O. &s iLYB,SIK., CA 96101
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<br /> EfE AMOINI VE AMOUNT HEMITTED
<br /> CgStt MECEIGfD tlY _ __IAIE PfHMII NG f
<br /> NfO
<br /> —
<br /> � � � ' X / JGi =LI .
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