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APPUCATI011OR PERMIT <br /> _ �► y . <br /> Y} <br /> • "` ^---- SAM. JOAQU11WL0C4iA4EALTH DISTRICT � `? <br /> i <br /> 1601 E. HAZELTON.AYE, STOCKTON, CA <br /> w Telephone 1209? <br /> p� <br /> r.. r si.-s; +:.. : " ,,: : � rs-• �'�. .moi , <br /> e - <br /> PERMIT EXPIRES,1 YEAR"FROM-DATE,'i$SUEDtr: ..'A" f <br /> �. f 1 Wig. rtr� 1 'il {Conn lets in-Triplicate?`_�> i" ir <br /> P <br /> AppliCstid_n is hereby made to the San Joaquin Local"Health District for a P !it to construct and/or ku tall the workiliereln daipibed a15pRcstton iR <br /> eafr;lam y,� Joaquin Colin Oidirianca f+lo 549 for Na X9132 f6t weN/pump frr�tl thet�lsl fid!He�tati0rtii Sayrt JoagtrIl7 <br /> ;.d^fINIGO,�f1rr�pliertC9i1/1Ui'J� llff•�.� + S�e <br /> Lacel-HealthDisUicf3! rS <br /> 1"i.J 9:^[;rpWit`/ <br /> ! Job Address City r Lat SIzAM <br /> t <br /> i- rsi 1!lame.: L - Address � �; ..� .. _ - ...._.,:.,w.?.- *-^• _ <br /> 1iF F _. - <br /> _ .�' .� . <br /> arltritcter, t .,.Address CJC License No.;- <br /> ` 'TYPE OF WELL/PUMP: NEW WELL ❑ " 1WELL'1VSEU11 <br /> ❑ DESTRUCTI ❑ <br /> PUMP INSTALLATION ❑ S ❑ OTH ,❑ r� <br /> DISTANCE TO NEAREST_: SEPETIC?TANK '"SEWER SINESbISPbSAL PROP <br /> I Wl1NbATlO ;.AGRICULTUROTTER.WELL "PITSISLIMPS: N' <br /> isINYENOED USE T .PE OF WELL PROBLEM AREA` CPECiFI ONS If, <br /> " t triduatriet " - :7D 13pen�ottdrn ;:fl Merteta `` "nie "3n'li'il9tl'ExCavati0n "' tF WeNCrld r p ;�9,, <br /> D DomeaNc/Private ❑ Gravel Pack 4 Tracy *- _TY of acm # <br /> ti <br /> p'Public ❑"Other 0 Delta Def Grout Seal Tlfpe d Grout ## <br /> irrigation <br /> x Jlpprvx. Depth . ❑ Eastern Sue"Seal Installed:by <br /> Reptile Work Done I ,Type' of Pump i H P _ Stats Work Dane '~ f <br /> Welt Destniction- :L3: WeICf)iarr►aaer, -Y Seating Mata .stop 50'1 <br /> �" 'pep1lt Rller'':Material 50'1 <br /> TYPE"OF SEirl#C WORK NEW INSTALLATION-0'.',- <br /> --Z:'. <br /> „REPA!R/AODITIO _DESTRUCTION.p [fslo_sepfk;. ii ptrbTic :is T� <br /> r Y y available #n 200 feet 1 j <br /> tr r 9rtsteUallon wlll serve. R' dance <br /> r <br /> Number af_!'rvingi�nits ¢ Numbs f n z <br /> f' racter 41 <br /> W ' aWe'_deptlr <br /> TAIVK"i 563 `Trpi(Mfig Capgcity A ti t <br /> PKG.TREATMENT PLT ❑ k j: <br /> M f s ,• is <br /> 1 S Distance to nearest. we 11 oundetion T� Property t , <br /> CHING LINE a ' �1 No &Length ot�liitean } }' iT;ojal: +9ti+/ <br /> FIL t la <br /> BED: ❑ 'd#atarice to neires ' 1iV�1aundetion Property Line r <br /> SEEPAGE"PITS flapth Size r 4 Number <br /> t. <br /> SUMPS ©" Oistari�to nearest: Well a Foundation 0 Propertji,Line i <br /> DISPOSAL'PONDS .. C7 <br /> I hereby certify that I have prepared this application and that the wo N be done in accordance with San Joaquin county ordinances, state,#aws and <br /> rules and-regulations of the San'Joaqui6 Local Health 1]istrict.' <br /> Home owner or licensed agents signatunibartifies the"following: "1 ce _that in the-performance of the work for-'whicf�. 1,pemrit Is Issued i�slraI not., <br /> f.'..employ ally paraori in such"rneriner as to becorrie-subject to wotkniarY'S Cbm0ensa6on laws"of.Califomia.'"Contractors hiring or aub-contracting signature' <br /> certifies the"following:" I c�rtify'that In the,`performailce of the worjc fo(wb'L this permit is issued,i-shall employ persons eud}act to workman's compensa- <br /> tian Yaws of Calrfgmie'- riF x" <br /> The appiicant m at cal!for all repute tion mplete dramng tN'� reverse side.. <br /> L itle ;Date' <br /> Signed _ <br /> - R D ENT USE ONLY <br /> Application Accepted by `r '• 'Y <br /> Date Area 1'^k <br /> PR or Grout Inspection.'b. + Date~ Final Inspection by; _ Date___k—L - <br /> Additional Comments: <br /> ❑ Stk"486 8781 <a„I `❑"Ladl 369-3621,' ❑ Manteca 823-11: © Tracy <br /> " ntal Health Permit/Servicef 1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9=1 <br /> Applicant- Retunn all eopM to "Envie tn5te <br /> FET° � CK <br /> UNT'C]UE AMOUNT REMITTED y '_GASH RECEIVED BY DATE PERMIT NO. <br /> i INFO” <br /> k <br /> EN 142Y' - <br /> y <br />