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!� APPLICATION FOR , AR <br /> SAN JOAQUIN LOCAL HEALI I DISTRICT <br /> 'kept/ (. P 1801 E. HAZELTON AVE., STO(KTON, CA <br /> TeleOwts (2091 4WMI <br /> PEWAIT EXPIRES ', YEAR FROM DATE ISSUED <br /> -- iCompleta in Triplicate) <br /> Appn•ca:gn r hereNrY male to Ow San JoMWM LOCO HMIlh Deme[for d prt,w to r trust awa/or ietel the work torero desortod-Tn .ppicatin. <br /> nob M t.onplrxe with San Joao, n Colmly 0 dkM No.SW for eewpe a No.ISQ'a wt1/pump A'.d"K.4 1r Re,"tic n Of the Sen Joeown <br /> Local Merth Dingy <br /> ci <br /> :.b <br /> Ac., - ���.—y,(1�_LYLI�. Crry�] •[a 5oe `,/,PM <br /> she�('/ .'�/-1/�-r_s6J.'.1t.. ./ Atteres .� •�� (' Plwrr ; <br /> :orva.:.."F fNFmF 1J.._l�•_ 7 t-•-' (,ors.No. .�c J"�n-/n Photo <br /> TYPE OF WM/PUMP: NEW WELL ZI WELL REPLACEMENT DESTRUCTION ❑ <br /> fYFMP INSTAl1A c SYSTEM REPAIR)C OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO._PROP.LINE <br /> FOUNDATION AGRICULTURE WELL _OTHER WELL PITS/SUMPS V <br /> INTENDED USE TYPE OF WELL "Ole"AREA CONSTRUCTION SPECIFICATIONS <br /> G YduMrM ❑Opp Sorwn G Mp Da of NMI Excavation Dia.at NNE CaYtp <br /> ❑Dotrtawfe/Ptww C GrFM Pea 'J Trery TWO Of Caeiq Spocdcoll IF <br /> 0 Pkele k c Once G CIO" Depth of C~SW Typo of f mum <br /> C Mrlet —App)..DTM 0r CMW. Sq%M SOW MutM.d br <br /> Rp.Ir Won Done jl- Type of Puny ,-A- H P. I /r. _ State,Ww4 Onti <br /> WON DFdntLTio. _ W41 ow~ _ c I Mewfiel lap S?I — <br /> Depth_ Fir MMaW t1Flow S07 <br /> NYPF OF SEPTIC WORK: NEW INSTALLATION(' REPAI ADOITION C. DESTRUCTION'; INO+epee LYFMn prtNttwt 1 pubk sewer Y <br /> araY40M wNh4t IDy IMt.I � <br /> Ittralaoon.ase Fe1N: IAFeerpe— ConnwN:M — <br /> Nunllrr of tA'ltn Orwts _ Numbar d bFdrdone <br /> ChW*CW of WF m•690h of T Mw: tseY depth <br /> SEPTIC TANK ❑ TM.IM/p _ ,_— ___. Cspec+ry._. No.Coaggeth Fna <br /> MKG, TREATMENT PLr.❑ Methad of DipxM <br /> Ootance to rotor: Well FouMatwn .Y._.— PtoWrty LW <br /> LEACHING UNE ❑ No.{Lwvth o:tie �_—______... TOW ernplh/aue <br /> F1LTEP SEO ❑ Ostarpe to wFrwt. WA _ __.._ FoutWtlan Ptopenr LWA <br /> SEEPAGE PITS ❑ Depth ._Sue , Nwnbw _ <br /> SUMPS ❑ Or to neerep' YM___— Fow bon_ PMPWV LiN <br /> 04SPOSAL PONUS 77 <br /> I holdbr 0101211."1 by Pepred tN applrwan"tHel t>r Woa Wi M 00n n AIC aW ca with San J04, r lo'-Ty odro 'auto lawn.and <br /> nAw and MWAO pre of the San JOFV+n Local M"It l D.vrct. <br /> Hato a.eter or breed apera'e Fpnelure ortMae she 1Wownp.'l ceroty dVt n th.pwfo tante of the wok fu Woch tho pw.rvt s i *d.1 shall not <br /> atopen arty re'eon n Fu1n nnrutw as so oeoos Kkw to waerwt'e cw prtutptt Ywa at Gawp --Cont www 1u40 o auDcanpacwQ wgnarun <br /> Mto w the MFOwiy:-I Qr ft sot n eM pwft w of the wk Io.lice the print a"Uwt.1 Yea en'pbY persons welect M Wokmri a coperpa- <br /> am 1 W of CAMaow.- <br /> TMappI MK' �4 FY Y nP/ed',p4Pat)O^e CaeFAIM ba'w"1p M""Md <br /> FOR OEPARTMFNT USE ONLY I�ty <br /> AppeoFbrr Aoop�g4y Dao �ZO'�'6� Arc <br /> Pax GraA FttgecSytt A - / Ol•" _ FiMI Wect'.a M li:.:S.'snLc ..�_ tw S �J <br /> Atelotel Ccwarge <br /> .7 as af166Ai ' :. tna ]SS.TpI Mewlaca Ba Iter :.:It a <br /> AppSptrl R~h4tll now a:Flwrabn~Heeth Pwr.aT Sa "ISDI F Hai~A.e..P.O.Son]UB. Ste..CA 96107 <br /> D ` A%00DT IDRt�Mh.A•.UV^IJ soy, 0101":10 T CATF IIRWT h0 <br />