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<br /> APPLICATION FOR PtwvitT
<br /> SAN JOAQUIN LOCAL HEALYH a(STRtCT
<br /> 1601 E. HAZETON AVE., STOCKTON, CA
<br /> Telephone (209) 466.6781
<br /> PERMIT EXPIRF i 5YEAR FROM DAVE ISSUED
<br /> (Coltlpiete in Triplicate)
<br /> Appl,cat,nn:,ho,oby mane to the San Joaquin L-ocai Hadith D'str,rf for a permit to construct andlor install,he work herein described.This application 1s
<br /> m,rde,n rn.,,pl,dnce with Sa,Joaown r,nt.nty Of,flnance,No.[99 for sewago or No. 1862 for we111pump anti th,j Rules and Ragulationr of the San Joaquin
<br /> [.,,:tat f{eilvi Distncr, y{' p•
<br /> _ City " " Lot Size,
<br /> '12 jr PN1I
<br /> Job Address / �/ -- r
<br /> Atkdras5 `F / . C`f_, Phnno
<br /> nsvr,ar-5 Nerne — � c�JG"1•J C:,G i
<br /> 1- -
<br /> --rf � �' : "c -� �1t � Phon _`�
<br /> COnIriCiG ?'r ACiress/ Licc
<br /> TYPE OF WELL/PUMP: NEW WELL t] WELL REPLACEMt.NT l-1 DCSTRt'fTION 1-1
<br /> - --^-- PUMP INSTALLATION D SYSTEM REPAIR i-i OTHER,V!-roe
<br /> DISTANCE To ivEAREST: SEPT' ' TANK _ -_ SEWER LINES .--_ -- DISPOSAL FLD.- PROP. UNE
<br /> -- - � FOUNr'\TION ___ AGRICULTURE WELL —-_ OTHER WELL- PITS)SU,MIPS
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<br /> INTENDED USE Y TYPE OF WELL PROBi.ENR AREA CONSTRUCTION SPE--tFfCATilONS !
<br /> i Inaystri.l -- LI Open Qottom� fl Manteca Dia. of Well Excavo.ian l& Dia, of Well Casing
<br /> y�43omestic4P6vate 1'i Gravel Pack I i Ttacy Type of Caging- /-, --- Specifications
<br /> 4 ' T of Grout `_ --
<br /> Puhl,c S1 Other Serr`/""41 l Delta Depth of Grout Seat •--/ - Y
<br /> Ap;nox' Del,th 1 i Eastarn Swiacu Sual.lfioal!dd by M.`�t_i°� "`/�`c�,y� »--- _-^^ f'1`
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<br /> Repair Work Done I! Type of F„rnp l I.P. _ ___---„-----.- State Work
<br /> We11 [)estrt,cnnn 1 Well Darmrrer _-_.____._-.- Sralin{l Material (top 50'# --.._..Sf-ir'•"��'=----.-.- ._---.---- r Ll
<br /> Depth filler Marlerul tEatow rc7l ---
<br /> T)'pE [)F SEPTIC.WORK: NEW IN7TAI,i.ATIDN,W 11EPAIR)AD0111()N I i DESTRUCTION i I (Nn sopa. 5y4lns,permnho it Puhl,c Snwor is _ -
<br /> avadrilile witltin 200 feot.l
<br /> Instaldauon wdf serve; Resid,ere Commercial_ Other
<br /> Nvm[)er of l,vmq units: - Nurtibor of badroums
<br /> Ih ____,,.Wator table depth,,..--.--.__
<br /> Cl,araGtnr a{ sail to a depth of 3 fret: ._-_-_-- __�_�---..-.r�.�-._._-- �•�
<br /> ^,EPIIC TANK i i TypelMlrl No. CompsrtmOnts
<br /> PKG. TREATMENT PLT,1 I Method of DiSPasal _
<br /> Distance to nearost: We11 __. _ Fntrndatiofo .�_ ___-- Property L,ne—_-,,,_._.—
<br /> LEACHING [.INF I 1 No & i-englh of tines _._.-__- _ -- r-__- - Totafi len;;[hlsiza� �_� u._ -_ -.�.-- •�i
<br /> FILTER []ED t 1 Distance to neatest: Wetl fr ._ Fourlowton �_ Property Lino. ----
<br /> SEEPAGE Pi 1 1 I Nin ltrtr
<br /> SUMPS I I' f]rtani;a In nonrom: Well fu,.r,tnhnr _. Pr;,p01:Y Linr --_
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<br /> D1SPnSAL PONDS F i
<br /> ha,c)y cwtdy that I havo wup.'trUri Rriti appSiLnl;an and that 1Lu work WA ')t)dung hi a,:r,Ordanre w,lh Sart.Joaquin countY ordlnan„t5• stato Iawfr, and
<br /> rust•, ar%rl re41ulnt,ur,y of the Stn jo;igmn $ot:ul FIealth Dlsfflu. i
<br /> f1nn,0 r,tvnur ur iu,,,wnd agonl's s:gnattim rnrlifins tho fntlnwrn[I: "I cattily tfum in Ord porformnnce of tho work lot which this potmit is i,sued, 1 511014 not
<br /> unit=ley nnY porton,n nr,ch murinnr nP to i,ncmmn fn,liincl to WW1,10An"S,:lnT,pe0%;0ion lawn of f.11iifaf n,it.”l'.orifilrrtnf'J hirinil of cuh convacting siA n,ILIr6
<br /> r.nrhfus4 the,follnwu,t= ,I curtrly Ihnf in am tterlmmmnrn of i1w work for w'h„-h th,!,Perin,f I.dsuad,f r;hall employ perwur o 4ubincl In wwkm,,rl'0 r-nmpnn&[t
<br /> Iron i;.ws of Cohl,ar.,a."
<br /> The inpliT.ont ms,;l cull for ar requand inspoctioos. Cnmploi.)rlruwinp on mvw%n sir1a, -
<br /> �il� T,tla �'` r 'J J,_» ��� f c_'•i _/ _-- Data; -i /`_�f --
<br /> Signed X � - - -----_- -
<br /> "� FOR DEPARTMENT USE OLLY
<br /> ✓_VtiV.`��-E.�� r)a,p�y/�)- '7 ! _ Area
<br /> Appl:rat'un Acc.:ptr!d ts'v --. �- ----_....�..,.._..,.�._�._ �N-• - /�}.
<br /> pit of i7pm,i In.rK,cuon by . - . -_ __- - .n Daln _..� _. P nnl InSrpr-rct,un by/� r-111 -'-s` Onta/[�•f r `�-
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<br /> Annit,.,r,;,l l,r),nrr,n.nty ! K_f1�,�_l_rt. ('.".-rTtM.: J,.rc✓ '- --'S_.f.�f'i�"3� �r� Y�-.rlYt7�(r'�-`5. �> _5l.�'%T� .l-: ..G-WA�LlG1� &L I
<br /> S;t, efdr 6181 . . Lotl, $fig 3,2: lllnnt n,:a a23 71(A r.' Trn,y 835 r,'Wi
<br /> rpr,lies o; R❑t„rn all copes to: [nv1,(wmentn1 Hoeltn Pormii!St,rvicns IWI E. rtar,�ltnn Ave., P C: r';-x 20M., S*,1„ CA I)Q.01
<br /> r ;riI - 1'hi� f,i'ClI':Fi) Dy•••-••.� [,1.Sf- Atiiwl; NO
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