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APPLICATION FOFt PeaAArr <br /> SAN JOAQUIN LOOAL HEALTH ALTH DIMICT <br /> 1ID1 E. H+AZE:.€ON AVE.. S€OCKTON, CA <br /> Tatlsphone RIES) 415-6757 <br /> PERMrr EXPIRES i YEAR FROM DATE I$gUgp <br /> IColnp(ete in Triplicate) <br /> •pplitntion rs►+ereby mstici to dte$en Joaotrin Loral Health District for a awmri to construct and/pP reftaN the <br /> Local H compliant*,Nigh Sart Jopga�t County Ordirwmg No.So for s w&"or No, 1 fo►was/ <br /> Local Hoaleh District- work tterrin Th?. <br /> I Puesep and t"Fluke and Regulatm"at tftf S hu, <br /> Jots sddrafa 1i�teXA <br /> � nw is p <br /> City Lot Size D dere <br /> Owner's Namer' lj ---��_ PM <br /> Address •L7. � <br /> � � G p a <br /> contractor a Address •[�. bona S <br /> TYPE OF Wi;L /PUMP: o n License He. fl <br /> NEW WELL ❑ WELL REPLACEMENT ❑ Phone'116"s <br /> NEW <br /> PUMP INSTALLATION Q SYSTEM gEPAfR [� DESYRUCTION <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER Q <br /> SEWER LINES _ „ DISPOSAL FLfl.` <br /> FOUNDATION AGRICULTURE WELL PROP. LINE }-; :To <br /> INTENDED USE —� OTHER WELL / O/ PITS/SUMPS <br /> TYPE OF WELL PROBLEMARFA CONSTRUCTION SPECIFICATIONS <br /> ❑ lnduatnal Q Open g <br /> ❑ flomestklPritrate Q A�aretsea Dim, of Wom Excavation <br /> ❑Gt"Pact ❑Tracy T ��� Dia.of Well <br /> f Public r7 Otlmr Type of C S <br /> ' I lutga[xfn rl Delta Deolh of Grout Seal Pae[fif Grout <br /> Approx. Depth I I Eamern Typo of Grout <br /> Repair Work Dorm Q T Surface Seal Gsatllged by <br /> Ype of Pump �� H.P. <br /> Wad Dsftruetian wen Oirfrtatp u - state Work pons - <br /> Seating Matereq Itop 51Y) <br /> Depth�j�D__ � FAA Msteviat t@afow 50 <br /> _., TYPE OF SEPTIC WORK; NE43 IA15TALLATICN! i REPAIR/ADDfTION I 1 DESTRUCTION <br /> inaMetion will fenrv: Readareee y_ C av to aritmm pfe".Iled if public savwsr is <br /> i G7Y11�Ci}Jf W9tttal�}aft.! <br /> Numbur of 6vinq limits Number Of Other <br /> CAaratsai of sol to a depth of 3 foot: <br /> ePTIC TANK <br /> PKG..TREATIIR•ENT PLT.❑ Type/Mfg C Water tolls datstlr I }p <br /> f --�� No. Corrq <br /> ! t. Oi�reca to : Woe_� F M*Wmd of Diopma <br /> rxatdateort Proparty Lkw <br /> LEACHING LINE Ll No. A Latgete of t�lm <br /> r FILTER BED ❑ Diotmrtof to rtaatsetg; wis Tod gtttlof" <br /> P"Opoirty Lin.� •SEEPAGE PITS I I Oapth <br /> l SUMPS LZ �.`.wSiae N++rreBw <br /> c , DISPOSAL PONDS Destareq m�emaaC wr F�+rmdarian <br /> k i p hoposty Line <br /> 3 Wil. I Y cortiflr rho I}tetra praperad pfliy � <br /> and tflet flee taletfA Will t►a <br /> { Herrn Q� Harte of the Sw JOWPA Lola)i1HOPdit D�trtst. dam m a=rpf=wie:Saet Jaaptrin <br /> employ a"Parkce'in atich "I CW*that in Utt► eStrsly ordinfetees•sats 4ws, aged <br /> ecrtifao r foBewfnp:',I cerdlq*M in �e�pr a1 rexwww a�Ilm of d the C ar fw hidl d*paomit in idwmd I sham nw <br /> tion Garro.of Califfwat <br /> I The amt 9+�eia." 1eL reAtiele this aasrnrt if s 1 ofeeB err4fty OWMM to <br /> for 1 pmraw <br /> M� aw'"V m wsrr Side" <br /> Title: i .vets. <br /> . c <br /> Swta�4a.t <br /> - - I - — O <br /> - - - 011PA Tlaasv�u ONLY ... <br /> Dam: _ <br /> i A011CAtlGtf AcseppW by - - - <br /> tr«• Pit Of GMn ire by D= <br /> r �dttfilonetlarrftrofec� Delta. �._ Fiteal iAlpa �f Des• <br /> I E ❑Sgt 1 p Lad ^•�,. <br /> : nasal . o lQ�•7iof o T <br /> Apa++�+mrit Rau"al!mvl"to: i�¢erreit/Sotvtema <br /> 1m1 E. H <br /> SIL. !ile3G9 <br /> ell <br /> Alto AiAOlW AEIArMo <br /> 1.., CASH A By OATIi <br /> # .Rel tx71tlOQll.trn!r P Aw'No. <br /> - <br /> 1 i- <br />