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Now �. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 4666781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ApF4<st-n n hwabv mads to the San Joaquin Local Hoeft District for a permit to construct andi or instsa the work herwin described. This application is <br /> made m comohinck wrrh San Joapurn Counry Ordinance No.619 for sews"or No. 1%2 for well/pump and the Rules and Rayvlations of the San Joaquin <br /> t ncar Health LigstrKt_- l\ <br /> Job Arldrwsst !oCity Lot Sin PM <br /> Owrm's Name``STS- ' - -- -- Adrkess gL�IQ��+ t"` • Phew <br /> QQ 1 <br /> Conttactdt _ O Address :e, ? 767 Off•`�t' License No. lei Z� phone - �e <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION ❑ <br /> —^ PUMP INSTALLATION 11 SYSTEM REPAIR [I OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK _� SEWER LINES -_ DISPOSAL FLO. PROP. LINE <br /> - �— FOUNDATION _ AGRICULTURE_WELL _ OTHER WELL WMISUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [] hdtrablel 6 Open Bottom 0 Menace Die. of WN Excavation_-^-- Dia. d WM Caoft <br /> `•;�tnratrerPrivsr� U Gavel Pack 0 Tracy Type of CnkV--- SosciliCiftwo <br /> .tbke ft Other (l Doha Depth of Grout Sete _ __-__ Type of Groot _ <br /> ar,q,r�cnn - - Aplwox. Depth I I Eastern Surface Soo Installed by r-- - <br /> Rwnmw Wort Mww l Type oA Purnp M.P. _ _— -- Stam Work Dona - <br /> welt DasNuchon i I WN Oi rneler Ssabv Mwariw IMP 50') _— <br /> Depth Mwwtsl( 50'1 <br /> TV pi X rJpJtC MrORK. NEW INSTALLATION I 1REP /ADDITION kw DESTRUCTION l l INo septicsysasm if pubsc aswwr is <br /> avedable w(thin faet.l <br /> Irstatiaslor.a4 so we: A1tca t"I" CarrwsreiM <br /> Nu vtba of kt w9 urYM 1l a im-1 7, <br /> awwacnr N uail N a dowo of 3 last: Www able dspMt <br /> sE!'?IC TANK 1.3 TttMlMMQ Capacity--------_. <br /> Ne. Canprtnww <br /> PKfi. (11EATMENT PLT.[1 MO!~Of Disposal <br /> Ohststtea to naereal: Well — Fourvtlation --- _ P►opaty Lim — <br /> LEACNINO LM 1 Mx,S LanOth of Wtss _ Total 101011840 <br /> FILTER SED [1 Distance to na~,' Wall — Feundslion _ Prop"Line_ <br /> SEEPAdE PITS r't�DapMt -D[� - SiasNumber_ <br /> 3UWft l 1 Distance to no~: WN�QQ� Foundation Mowmv LOW <br /> DISPOSAL PONDS i) <br /> I hstabl!cars,►Mist 1 have alraI . cotta appliC tion and Mtw/thou wrw will be done in accordance with Sart Joaquin county erdkancal.state testis, and <br /> ilea oral tspelsatarts of dw San Jes"Mt total Health Distrkt <br /> Haws awnew a lisarte"apris's tllV I- *WdVM Ilia 1e0fatiry:'1 cglWV that in the pertorrnenee of the work for which the twin*s isattsd.1 slap not <br /> rhplstf anti pours,Iw wait rttmmm as 0, . atrblact to workman's oontpartswkhn laws of Cswornia"Contractors i,ir'no of sub conhactiry Wwwh" <br /> otealpaa Ica tapes w"I caraMtr Mist w 00 polar 4wwa of the work for which this permit is maued.1 shah antpby POrS's subject to wrorkrnan's coo rtpwnso <br /> tion"we of C&warnht." <br /> The sppkcant sill 1st tl d Mnapacfions. CarrpMa drow+np on fever" <br /> L - TiMr ---- �...� _.._ __�__ Dab:�Q (] <br /> Ssptad 1<.-� —-- - <br /> IrQ POLI DEPARTMENT USE ONIY <br /> Appktatw Accepted by r � -----._ Dsew " Awa <br /> e1.Opt Myon by (. Data�Fkssl MtprNwt by Dow� <br /> Additional Canuns^tr r <br /> SM 4011701 [1 Lea IWMI C7 Menswe 023 71M U Tracy 0Jb X306 <br /> Ap/1t Mtt Reston M aeon b Efwrrenntantsl HaMth Parwtlt/Servieas toot E. Harehon Ave, P.O. Sett 2000. S*..CA 9=1 <br /> isAMOUNT Ole AMOUNT etatNITTED cu ASH h1ctN[D ay DATE P(fIMT NO <br /> YMO 3 <br /> /7 B4- <br /> t ,t r <br /> too ' .. <br />