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APKICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH nISTAICT <br /> 1601 E, HAZE'LTON AVE., STOCKTON, CA <br /> Teiephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> lCornpleze in Ttipfieate) <br /> in Local H**th mstric,for a pe;mit 10'tbl%truct and/or im-*J th!O Work hOye'n in <br /> AV,,4"t0n is t*veby Made to ths SdnJ0aqk', tditul �544^;for saWS94 or 14o. 1962 for wet/PuMP IlAd th6 Ru"and tet Of the San jooquii <br /> made in crvr­.vtiar- vvfth Sar,JozcIu4,q Cw')tv 0 <br /> Local h6eth Dmtt'M <br /> PM <br /> job Address; <br /> Phome <br /> dress <br /> M WELL REPLACErME <br /> Ypf or IPUMP" NEW wEa <br /> PUMP INSTALLATION _tg SYSTEM REPAIR z PROP. LINE <br /> ,DISTANCE TO NEAREST, SEPTIC T ANK SEWER LINES _ .'___ DISPOSAL FLO. PITSiSUMPS <br /> FOLINDATION, AGRICULTURE%VFLL ___ OTHER WELL <br /> PROaLEM AREA CONSTRUCTION SPECIFICATMNS <br /> INTENDED USE TYPE OF WELL Dia,of WOfl Casing <br /> 0 Open gottuarmn r-1 manteca of�V&D <br /> Industnal .46 <br /> f- Gr"of PaCk 174 Tracy "Typo*f Casing_. Type of Grout—, <br /> I"';outer1,1 Omto Depth of Grout S62d <br /> sugface S"t t"talied by__�, I <br /> 1 1 IT140ton <br /> Aepail work Done vftoT"of Purrnp H.P. state WCA Done <br /> wail W611 oiattNttar <br /> owl,, N.- <br /> I IN.zi' ";" ponyiittod P. <br /> INSTALLATION' Vt ii6WRI^0011M <br /> TYPE 71VI-SVITIEWOR NEW INSTAL vViIiiin 211 f"t') <br /> Installation v4i"saws: Adsk%&MG <br /> _-- <br /> Number of living uNrc Njrnbcn of bedroorni zzlbw depth <br /> CrIalarle?01 teff to a depth of 3 teat: VAIS <br /> SEPTIC, TANK C1 Tvpe1;k4fq N_ <br /> MjgnCki of Disposal <br /> PKG TREATMENT PLT.173 Dwtancu -o m6arast: Woo Foundation Propsay Lina <br /> L EACIIING UNE n No. A LenVth of ariim <br /> FILTER 860 U Distafsca to n0af05;-.: V" FoundatiOn L!ww <br /> Numb" <br /> SEEPAGE PrTs I <br /> pfopww Line <br /> SLIMPS 4-1 DW=nc*w rmarosc- WW_ FGU"ds*M <br /> DISPOSAL PONDS 0 ce wan can joaq-,j;n c"nty ofdintnc4as,Irts"laws, and <br /> I h*4 y certify that i have prepared this aprlialt,611 and that the w(Xk Wjl be done w accordan <br /> rulers,and regulAtio 00-tftw!&4"-n j Local Health DiVI"M ',,shall not <br /> "I certify that in the Per' <br /> orrmned W*he workizv which"patnvt is i,_umd. <br /> Hoi-ne owner co agan ttJ C45rt I M• T*W I' S''s nornpensation laws Of Camornia."Cnnttactof'4-hiring Of sub-cOntrac*'riq S'Oftz"ye <br /> -an <br /> ernooy any v tpKv�rin "uad I 5t%at;0,play po.r,%nns subioct to vw'0fkn*-bn'1 cnrr4y&O"- <br /> , dowing'"I cartsty to the a th w Xh that:pernut is i <br /> camfiesthe <br /> 14on lawd <br /> Tt,,e aptil an'in Cal requite F <br /> Date: <br /> Signed ...... 4f�104_ Tire-, <br /> FOR DEPART Mt <br /> 7NT USE ONLY <br /> Arse <br /> Apptiration ArWjtod tY <br /> Pit at Grout lntp*Cffon by Date <br /> Additional Comments- <br /> 0 Stk 466,6781 . C Lodi 369-3621 Marvtacs W-7104 0 Trach 836-638E <br /> rrt Av011 P.O. Box 20M, Stk., ^A 9520' <br /> Applicant-Return ail 00OW161 H051th Parv'S8'v`&%1601 E' Haze"tor' <br /> GASN RECArVED sy PEI <br /> FEE, CK A i <br /> AW.01-INT DUE AW) N1 <br /> 1100 <br />