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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209)466-6781 ^0 (-- <br /> PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ' <br /> Applgatioo a Itarebr meds to is Sen Jostaah Local Hearth Oat&l fa a Pwmit to eaapu<t wdlot irotad the work twain dsecrbed.ThU-MPBted-a <br /> nOft in ooheodwce wish San Joewit County Otdtrurce No.519 for`eatvaae w No.1BG!for wmp all/puand the Rules WW RaOuistlors I9 of DSan JoeVuln <br /> Loch IHMIte Oiltri . ��J C`S�1r �,� <br /> Job AddressAC—. ^ ".{ CnY�OrzG=-+—Lot Sia/3�� vM . <br /> Owrtw'a Nwrr 7 Addrns ^L — — Phone (. <br /> I CwWacsYs Noy No. - <br /> Phar <br /> TYPE OF WELL.NPUMP: NEW WELL C WELL REPLACEMEWT 0 DESTRUCTION 0 <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER 11 <br /> DISTANCE TO NFMFST: S@TIC TANK SEWER LINES DISPOSAL FLO. PROP-LINE W <br /> FOLINDATpN AGRICULTURE WELL __OTHER WELL_— PITS/SUMPS DO <br /> INTENDED USE TWE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Z,fnanoal - G Open 9nnorn 0 Manteca W.of Wad Excavatio Dw-of Wes Casing t+ <br /> 0 DO..MWPa 0 Grwsl Pact, - Tory Type of CaainO— STecificwions G <br /> C:Public C Otlw 0 OWn Depth of Grout Seel __ Ts pe of Grout <br /> C In avow —Jlppoa.D-pth C.Eacrn $cacao,SW Installed by <br /> Rpm Wort Dory _ Type W Pump H.P. Stage Wok Done <br /> WM DaNucao C Well Dovyter SeaErg Materal It v 5O) 7f <br /> Deet _ Fidler Mot"(Belo+W) _ �--- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADOMO .TESTRUCTION G (No septic+ysttmt Pwmitted it Pudic aawer a <br /> available within 2W feet.) <br /> b st aston W sero: Reaidwca A Caarygciat _ Outer _ <br /> Nhgribw of Twig testa:_ Numbw of bedrooms��— <br /> OMrkar of end to•dapeh o13 fear _Walw Islas depth <br /> SEPTIC TANK Type:Ml/ Cawhv 4L.('_— No. ComWnnynts <br /> PKG.TREATMENT PLT.C ' `_ _ Method of Deposal . <br /> Deeoce to nYmag: Wad__ Foyyation Property Lina <br /> LEACHING LINE !k No.A Length of Gros ��n N Total a <br /> bxgth/fbe 't — <br /> FILTER BED C Da to ue,to raven: Wad L-s.— Foundation plyProperty LMe tj4.Af—- <br /> r <br /> S®AGE PITS1y Depth $4e Numbw <br /> SUMPS C D"ytwKa to rhewNl• Wax foundatio:t . Property Lkw <br /> GISPOSAL PONDS C <br /> 1 hmW owbfy 11W 1 have prepeted this applicabo and that the oak wal b•done a eccortlance with Sen Joeyuin county en6 wcne,state&IMM and <br /> gulp and rWAgger ,of the San.Yiapuin Leal HssIN Oab(cl. <br /> Hoy raesyg w aeange0&9§Wg w9m m a cwufim the following:••t avch that ut the pwfarrance of the work fa xAlieh the p0teat a humid.1 shall not <br /> employ say y.yon w such nyrayr as to brant wrbtect w worlunWa co<aenaation leas of Calilomia.'Conotcules hiig Or a✓.<ovacWg Iipnetute <br /> cardrAs to fodotwg:-1 cwth Nw to the pwfwmanca of to work fw wfs%tha cramp a I=".1 Ahad WM)Ioy PWsmn I&MICt W wwk—W$cOmperua- <br /> tan awe of came^i-- <br /> The appku tt f<d fw rsaied gory-CornpfayrFav,tny ra tide. O <br /> Sign Teas' _ _ —_ Dote: e <br /> i <br /> WAD ARTMEMT USE ONLY <br /> Appiriiwn Accepted by � Dam T�� L <br /> I R 6r Creat Yweclio by - ! I a�Day.� / -� �iyl bspeccon by J_3S_� pp�� Date :py <br /> / <br /> 0 Sa 4054M 0 Lad 309 fMwq <br /> ) r:MroIU:FTracy <br /> 710f 0 833 61B5 <br /> Appdrare-Ilea lee of copy to Fiyiorameagl H"M Pamit/SWvkye JODI E.Healtnt Ave..P.O.am 2008.Stk..G 95201 <br /> CK 9 <br /> mAMOLMw DUE if AsaWER REMITTED FJtSH RECENED By DATE PEP NO <br /> NFO /� �F/1 <br /> .N Oar tYY <br /> Nw <br />