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z. No6311 <br /> APPLICATION FOR PERMIT <br /> SAN JOALQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1219) 4684MI <br /> PERMIT EXPIRES 3 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is harsby made to&a Son Joaquin Local Health DiVrict for a permit fa construct andlar install the work herein dasenbed.Tres apnlicsin*n is <br /> made in COMOM as with San Joaandn County Ordinance No,549 far wwe"or No. 118112 tot wail/pump and the Rules anal Regulations of tha San Joaquin <br /> Local Health Opstfict, yy <br /> Job Atltlress _� 19"A e" 41 ;r I ec.jr4L f l Ir..,_ c 0c City r Lot Siaa 40 aCi PM <br /> Owner's Nama Address �O ,c rt 4D9t Phone - o <br /> Contractor Soren Addras$k-, 50A OC[JtA rten ['r4 Licanss No.41JRZQO Phone'Vi O— <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER <br /> - DISTANCE TO NEAREST: SEPTIC TANK 10121 SEWER LINES DISPOSAL FLO. PROP.LINE 262-L <br /> FOUNDATION -_ AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> rr <br /> ❑ Industrial ❑Open Bontxn Cl Manteca Dia.of Well Excavation Dia.of Wall Casing <br /> g0oesm <br /> twPrivate XGr"Pack ❑Tracy Type of Casingd---q0 eve., Spsedicatione <br /> M Public n Otter 171 Oalts 04113th of Grout Sisal Typo of Grout Ani==-A <br /> + I Irrrgatrdn 'Approx. Depth I I Eastern Surleca Saar InstaNad 9y <br /> R7w Work Dore U Typo of Pump H.P. State Wont Dona V <br /> WON Destruction 13 Well Dwmtcw J� Sealing)mita ill!(top 30') <br /> Depth � ."�,_ Hilar Malaita!leakw 807 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I . DESTRUCTION I ! [NO=,Otic syt+tem peiimlted if public www is <br /> avttlte vwltit Zo feet.I. <br /> _. Inwtaastwn wig an Raeidance_ Comn wccW� Other <br /> Nurl*ff of!!ring units: Nuatbw of bodreo s_ <br /> Charactm of sod t6 a dopth of 3 feet: WsTisr labia osspds <br /> aEPTlC TANK ❑ Typo/Mfg Capwcrty No,qty <br /> PKG. TREATMENT PLT.❑ Mauled of Dispois <br /> } r" Diatan,=to niarost: Well Foundation r. Propwy Lite <br /> s LEACHING UNE ❑ No.A Length of line, Total kng1W5iwa <br /> l <br /> i FILTER BED O OWAnce to neo on: Wed Foundation Pr WW Lite <br /> i I <br /> SEEPAGE PITS I I Dsww — - She Number <br /> 1 SUMPS L1 Diotanea to tgllalw Wee Fourtdwtion <br /> j Isnopolty <br /> Lm <br /> DISPOSAL PONOS ❑ <br /> I hereby cwtrty that I hm propered the apps akn sad that de watt will be dome in accordance width Swt Joaquin cotwtryr ardintingm.state Law%,and <br /> ruin and requUtimts of the Stan JOmlign LaCld hlnft 040lct. <br /> Homo OwW or Ifuanasd apwafa ftlifilln tssttllim this ftlroeAng:"I Comity shot it this psirknnwas of tfte wO*for aloft fhia pattttl;is issued.I star not <br /> 7 "w employ only,pastnt in waft rttawslw ale fa b9owisa arAlaol se warRmen's coot tion bm of Calllernis."CentrocWts <br /> cwrtlfies tlq IortltsRrtg;^t cenitl►tl�t is Plttl paflmtrrrtlt0a d tile wort for wwcit tftia permit wl eras,l altos sottploy peraom tart to a atkntan15 sortrp <br /> tion Uwe of CaWarria," <br /> The appueant t aS lrwAvd WMcdow Contplew dm inn on nvows olds. <br /> 5grtwd% TMw: —_ l'I�tt f�ILCia� QA F& <br /> 'SIL k t �,•. �1�1++illvt� ���i r�faa�0i4�"_ •„�,-.^_ <br /> FOR 09PAMU&NT U88 ONLY <br /> Application AccapW by 0sm .,.Argo <br /> f <br /> Ph at Grout lnwpu*n by Data Find inapsatinrt by Osla <br /> AddlzbW Camwa m: <br /> ❑ $I$ AWMI CLOW M3Ul G Mwittow M7104 O TWV 81D4= <br /> 111 wit Rapes am Capias to: @mltowwRal Fiaatth Perri t/Sano w 10011 F. HatisI t Ave.,P.O.Do 2X@.SUL.,CA fit <br /> Nie AMOU t3tJr A111Q1INfT RrIINTTID CASH 1111:1MO BY. SATE. POLIOT'NO. <br /> . <br /> IN 1176 INV.rraaI <br /> i r• t�7a <br /> t <br />