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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 46b-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Tripli") <br /> ...ado to the San JoaQuin Local Hrralth District for a permit to construct and/or bwWO the wort hereM dMorbed.TME 000M1ation Is <br /> !h San.loaquin County Ordinance No.5"for sewage or No. IBM for westpump and the Rule@ and FAvAelihm eflim!Earl Joaquin <br /> 3.70D F . 1 ✓e r-k d • _ city i po n Lot sl:e pG P <br /> Uro_(An s L W� k[llAddness 39_l!� f K a �i�Qn Mona <br /> T �y <br /> Address Q I>~1 a LICQM*No. fthM <br /> L PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION ❑ i <br /> PUMP INSTALLATION ❑ SYSTEM(REPAIR ❑ OTHO ❑ <br /> To NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP.LRA <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - - Pf WSUWS <br /> n USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> - ❑Open Bottom ❑Manteca Dia,of Wall Excavation Ols.of Wla/Cwiq (� <br /> Pnvate G Gravei Parc C Tray Type of Canim SpeclIkOm <br /> C Other ❑Deka Depth of Grout Sal Tvpe of(Neat <br /> _Approx. Depth O Ese— Surface Sal t>'tafbd br <br /> Done C' Type of Pump __. H.P._--- Stow Wbrt Dale <br /> Cron C WeN Diameter --_— see"Material(tap 50) I <br /> Depth F#Ia MPWW 18Mw►9D) <br /> ,:FPTIC WORK: NEW INSTALLATION REPAIR/ADDITION C DESTRUCTION - ssptlt: a Ow0 maw le <br /> y� svaiEbls wi111Yt 2CJ 11NNE.I <br /> ".n well aer.e: Residence X Cwt me ciai—_ Other—►1_H" <br /> u+living uni' : _t— Number of bedrom <br /> e, of soil to o depth of 3 feat: — __._- W~qb"l>1Plf,.-- o <br /> est _ cap•dlr�r3r� No.eomfi.lmsnb <br /> Aca- <br /> 7ANK ------ <br /> 'ItEATMENT PLT. ` ' <br /> DlWttcs to rneareu: Wea _.{,emu_ Fou.datbn qtr Line <br /> ACHING LINE >4-c No. fl Length of Knee TOW Wqwsbe— <br /> LTER BED C Disw+a to nearest: Well Faatdedon /D PNOVIV Lb"��- <br /> 1 <br /> EEPAGE PITS C Depth --- _Site <br />.i r.f PS " Dia'snce to ne~: Fwndstlon?1�/ fsre""lila <br />!SPOSAL PONDS C <br />..or vl,y Cen,fy that I have prepared this application and that the wort wd be dons M aoeordsnoa with Sen Joequin cour"and iewwat,sow b ve•and <br />..r:;and reguistrons of the San 10aQuin Local He@"Ois*nct. <br /> nn,o owner or licensed agent's signature artkias the foNowing: "1 cestlfy That in the pufOrrnsrlm o1"work for v*Ach thY permit IE lesued,1 d"I not <br /> npmy any perwr:in such manner p to become putojeet to workman's oo WmigaUon(Ewa of CaMotttis.-ConveCto/s MCMV at cub-oontrec"fipnalrle <br />-mf"rhe foaowing: 'I carritY that aAorr <br /> l the pewtco of the work for whit"Irma tares is lasimlid•1 011A Mnpb'tr persona eUbfK't t0 wakrrlan's OarrOM! <br /> n le~%of l RIdomia.'. <br /> hr, A;,pi!Cart m�st Galt for as/ ulred mapett om ComVWte dvr^mng on reverse�si�de. <br /> 1n, / r C7 ----- TitM -.-_.V3�/_ ---- OM.�. S I� :+r. <br /> c�-- --- -- <br /> FOR DEPARTMRPfr USM ONEL1f <br /> 7 /3 -81 Awa OG <br /> Accrpted by -- A ` �— -- --- - Dele will. <br /> — /r _ Data_ Final Mrpectian by �1' 'Y�l�/�d.�� <br /> .. „11 Ir tklPC t.On by ._. _"� --- ---'- - - -- <br /> Comments <br /> �4 5M >09 3E21 Mentees to 7101 I 1 Tn" 8354 M <br /> I+eturn all ;oVW"to Environmental Heal"Perrrrt/Serview 1flD1 E. Hitehon Ave.,P.O.ffaa 70M,fit.,CA 9W,7Nt Io <br /> r FF AMOUNT OUF AMOUNT 01EMilTEO "Ice No Illy DAT[ 's11aMT NO. <br />