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<br /> ry �, 6lrh � ' r*alt % is •ATION FOR PERtU,.tfr ,_ k Sg p3.' 4
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<br /> SAN ,IOAOUIN LOCAL 4I ^t 7HMSTRIC7
<br /> a iLit E. HAZE`i OP% AVE., STOCK:I O?l, CA
<br /> Tefaphone (209) 466.6781t �Ii:
<br /> PERMIT EXPIRES 1 YEAR FROM .#ATF IS^.UED
<br /> tCnmplete in Triplicate) r �
<br /> A t .�canon s!c t y ME,-h.ro the San Jo'lqui 1 ocaHeat ' �
<br /> h s'rict for a permit to onstr,,ct I/o: „1 ,h, v.,•Y ,;n descr tire; Ths Dppfc0t:nn M,
<br /> made in cnmpL.r•Ace with San Juaquin Cr.,ntv Onfnanco rao,'0'or xr�,var a ur tJo. 1Elrr,hu w
<br /> ! p,r n>.9nd tho R,Jr ar;f t'r, fat;x s of the£sn v
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<br /> ocal Health D,
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<br /> Jeb Ar!1 '.s5Owner's Name f1N� � - ,;-AAdross .,. _ Pharu• _
<br /> . �,;{ r1 .!. ,:Dill/aL of - �I1�..CNr'.•4 �u— Addrnis
<br /> _ - L,ce se No ��/�___Phone/ oT,�_Je�c
<br /> TYPE OF WELL/PUMI" NEW WELL L'. WELL REPLACEMENT i`^^
<br /> - DESTRUCTION Li
<br /> PLWM'INSTALLATION f - ;'✓STEM REPAIR
<br /> -0THE9 i]
<br /> xa y. DISTANCE 10 NFARESF,..SEPTIC TANK _ SEWER LINES `: DISPOSAL F-D._. PnOV LINF
<br /> FOUNDATION AGRICULTURE WELL �OTHER WILL,---- PITS/SUMVS
<br /> INTEN_D_ED USE —�TYPF OF WELL ^PROBLEM AREA C_ON_STRUCTIOr r;PErIFIr ATI NS
<br /> "I,ft✓,i C.3 Tndu;tn,i1 i_J.Opan©Ottom -CJ N tnleca Oaof Weil Excavating D'ra,of Well Cairq
<br /> ! Donsestic/Prrvafe D Gravel Pack. n Iit cy Type of Ca};ng __ Specifications.
<br /> W
<br /> bL I f (1 Publit I7 Gthrr (1 Delta Dc Ih of Gran Sca' If
<br /> T a t $ p -.»._- YTu•a!Grout--- --- -
<br /> ,,, IrrrJ rtK)n., Approx.D PIN 1 1 Eastern Surface Sea!Instilled t v
<br /> g;=Repair,Work Done 11 7vpo rl Fiji rP _ H Slate Work Done-- ---_-- --
<br /> ttaJ,a tyr, ` Q , Wefl Destruction 13 We.:D6metnr �� Sealin NI'acnal ttu "0"yr
<br /> r �)^t I L I Depth Fillet Material(Below
<br /> OF SEPTIC WORK: NCW,INSTALIATIL.N I I REPAIR/ADDITION I DtSfAUCTGrJ I 1 INn septic system par, T' I
<br /> k7
<br /> / ` �O` I avaioble w1Ihin.'OO feet.! 1141
<br /> rnstellation will servo ROsidence Commercial 4! Other�rmber of liing un ts: Number of hedroornsSEPharacter of eol to a depth of 3 foot• - '�} Wter table depthTIC TANK I� TypeJMf C nCvCr/fl 1u_d�cr � � rC pTcty � .LSV ho.PKG TREATMENT PLT I! Methal of Dispoal„tc y :D stoner So nea•cst:.” Will _ _ Foundation Prc;lx•ry Line +�
<br /> LEACHING LINE. G✓No R Len
<br /> INF. of lin ---
<br /> �'' Y 1r es
<br /> FILTER PFO I 1 Distance-to neresC._ \be!---- - = Foundation __.._. P�r_,enr Lrru.
<br /> SEFPA!'c PITS- I /p��nth ��- Size__ L �'_ 7 r:rmber
<br /> Rh ':SUIdPS." I(J' Diirnnce to nearav: Well,:-__ __ _ 1 x.ndat on �{�
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<br /> /�(.- rC tarty Lnie _ -
<br /> i7 DISP05AL�PiiN.DS ('1
<br /> I hereby certify that I have preparod this apphcatio:,end(hat tho work will,rt dorm ill acc.),da,ce wi,h San ,aquin co(mty ordinances,sl—Ire Y'
<br /> ',rules and rogulations of the San Joaquin'n„al Heal:?,DistrlCL
<br /> f�t'1 •;4 , �k Y 1 r•Home owner w licen• d a,ient'a,!.jcaime uorlifira the following:"I certify th it in the perfoimar ce.u!the-ork for which this p,mlit is issue' 1 tMll nol yp'.,
<br /> employ any Derson in such -.nor as to become suhjoct to wot km m's compenvr t.on W s of C:I f•rnia."Cont'a ctw's hung w sub-cu+tract ng s.gnuturo
<br /> .certif"ws the foroWnq:"I mly that in thu yeryfgr,'Aacce of the work for whit''this.-its .•<f !,haJ t.rr.pby lersons sub;ect to wcri.man z g •,rr r -r
<br /> ;`' �y�•>l.�`r non laws cl Cahfornla."
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<br /> .'The aPpl, nt mus ' for all requir cabetfa r' Ntn orawinp on r�t-y S;
<br /> '.Sp, d > ---- - -. Titre: �C✓-c-.�c�`-- Joie. 1L t
<br /> FOR
<br /> (�DEP. TMENT USE ONLY
<br /> Application Acte ted h
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<br /> �Prtor'iroutlrp.Ytio.tby Date
<br /> :Additioul Comments.
<br /> L7 S:k ,46G-67^1 C, Lodi 31J 3b21 C vlantaca E23 T'04 CJ Tracy SlVr%95 o�.
<br /> a }, "q A IKant-Return er,c .Services 1(�1 C. Hazelton Avo., P.O. Boz 20GO, St,_ Yf 1 •--.v L� =y '
<br /> x pp copies to: Environmerial Health Pov it, rA r,
<br /> - b} AMOUNT DUEMOUNT REM!^E= CK f RECEIVED fv -DATE PEr1 MtT NO.
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