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APPLICATION' FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZEILTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES -1 YEAR FROM DATE ISSUED <br />s" (Complete in Triplicate) <br />Application is hereby made to the, San Joaquin Loco 14offth District lot 8 Permit to construct and/or install the work herein .This soplication <br />Made in compfiftwee with son Joaquin County Ordinente Na. for or No, 18W tot wollipurnp and the Rules and ReouWflaft *I the Son Joaqis <br />uin <br />Local Health District <br />60o4lu <br />44-t <br />Job Address <br />city Lot Size PM <br />Addrm <br />_ Phone <br />Contrac I Ell- Adtfress )" a, <br />MPFF Ucame tl <br />NEW WELL 0 WELL REPLACEMENT 0 <br />OMTRUCTION C <br />PUMP INSTALLATION 0 <br />SYSTEM REPAIR 0 OTHER 0 <br />DISTANCE To NEAREST- SEPTIC TANK — SEWER LINES _ DISPOSAL FW_ PROP. LINE <br />FOUNDATION., AGRICULTURE WELL — OTHER WELL......_,,,,._.,, PTTSjSvMPS <br />INTENDED USE TYPE OF WELL PRO13LEM AREA CONSrWCTIoN spEOFICATMS <br />i3 irxhrstrlal 0 Open g*nom 0 _&U-"= DID. Of Wall Excavation Dia. <4 Wall Casing <br />Domestic/Private 0 GtAVO Pack C] Tracy TW* <br />n Public Spodf"fioft <br />11 other 0 <br />qa0th at GroutA& sow G <br />X. DT4" Of mut <br />. <br />on NJ-4L,-�kRKOepth 1*1 Seal-Installod by_ar <br />_" <br />Repair Work p e r.1, <br />Typo of Puma <br />aw" Wo* Done <br />Well Destruction LA-Iwet treater <br />too I <br />Depth aria/ t8 1 W <br />TYPE Of SEPTICW,0w <br />NEW INSTAL t :1want R_.'- .V <br />- -4 1 -1.111 ­ — YsugttNlaetf»it'" <br />it public sewer <br />Irl t3fttiOn wit Sarva; Residence — otho M, --J <br />Number of living units. Number oft I AL <br />Charactw Of $04 to a depth of 3'feet: <br />SEPTIC TANK 0 T ypeJMIg <br />CepUjtV'___ No <br />PKG. TREATMENT PLT. i7 <br />Distance W641 Foundation Iitlxod Of Dispftai�� <br />*t — Prop"_ Lind-. <br />ft ' <br />LEACHING LINE <br />FILTER MO C DistantTotal W"wan ------- <br />WW Foundation <br />Prqmv <br />SEEPAGE PITS <br />SUMPSLl Distancd <br />to rwarest: web prop" <br />4SIQ:- Foundation <br />DISPOSAL PONDS 3 F <br />I hW#by cartify that (have piepw <br />_00ra, " that the work Will bo done ip, accordance V" "n Joaquin coutav wdwanoas. state laws, creat <br />wles and tiagulagions of fhg Sah-j�bquin Local Dimict. 404 <br />Home owner or i1censad avows skruftia'Caft ti . 1.1 <br />Wft <br />1�t . certify ."Wrho <br />arnploy any pwwn in such mwvw " to become perfort"ance of text wotk for which issuacl. I stem/ riot <br />certifies the 10110wing: "I c4rw that m the Ole Of C <br />40"10'"ation CoftaoWs hift of siulmumtracting signature <br />th8,jqWfw--"Idh' <br />bw WV" of Cawornfa." "fis Permit 0 muod, I W"d 0041010Y Persons, subject W work"nt cort"ns&_ <br />Inclappliczrit call tot an r ad cpnvk" reveries <br />Signed X_ <br />Title: <br />FOR qr'PA)ff <br />Application Accepted by <br />cttiGrogrJOSWtion by <br />lw Fin <br />Additional Comments: <br />0 Stk 466 -MI CJ Lod 369-3621 0 Manama M7104 01 <br />Appticent - Aetum all copies to: E"ronmet" Has" pamnjtjS#,voaa 16011 _As <br />AMOUNT DLM <br />INFO L_ AMOUNT OMTTet, <br />* 64 13-24 (REV, „,t sj 14T 7�,) <br />gh IS -20 <br />A ra a <br />kwWdM by Doe '1 ' <br />m Ai r,; P_0. qax 2bW S*., CA -OW <br />REJMIVFD BY <br />I no, <br />a <br />