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<br /> APPLICATION FOR PERMIT
<br /> i SAN JWU:N MAL HEALTH DISTRICT t 0, ft"�I
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<br /> t tt I601 �:'HA2ELT0N A+E., ',TOCKTON, CA §y # Fg
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<br /> hone {209) 466.6781 ntr z r9f X. � , o to
<br /> _AA K DATE I55UE0' � �i,
<br /> ' PERMIT ERPIRES`l YEAR FROM DATE yiL,���ai y rt
<br /> t,_ (Complete in Triplicate)""` ,,:, r; 14 ,}d1c. "Si•[plri , i1� `fYTrM, �i'y -
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<br /> `AQpIluEian is hereby made to the Asn ,kaaufn`Locel Heaith'District for a t?eimit to:elMitrucfrandJar..lnstxii1M �ork'heretnz- -iry
<br /> k t `,dsstrlbed, . This application is made in cArpliance with San.Joaquin County Ordinance No ,5A9.iar"0wSe di"r;lfo d862tfdr';wa11Jp�P''
<br /> the Rules end Requisitions of the San Joaquin.Leca1 F.ealth District. T , ?s. ygr� .
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<br /> r- yAddress SYhiYiS:Jab , ion Name K i' is
<br /> �OwercherAadress lo�
<br /> ;CNItraCtOr's Name ,,�R .�nAhso ,tcense No.
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<br /> i �,yJEyyTYPE O>!`l1ELL/RM WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRJCTIOM[�r.. syr. �t s itt ! t,
<br /> pumv INSTALLATICMI ❑ 5YSTE4 REPAIR ❑ OTHER ❑ 4e ::* v 3
<br /> t DISTANCE'10 NEAREST. SEPTIC TANK SEWER LINES D)SPCSAL FLO PttOr LINE b
<br /> FOUNDATION AGRICULTURE ER RE WELL _OTHWELL
<br /> PIT USiMPS
<br /> DPROBLEM '!fib ti
<br /> �°IN[�REO USE TYPE _HELI
<br /> . . AREA CONSTRUCTI011 SPECIFiCATIO:6
<br /> indn3ir1a1:;: ❑Open+BstRga ❑}lahtlCa
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<br /> tNWIic/Private 6rerei Pack '! ❑
<br /> ❑ Tracyelt ° Oia u1e iFe�F�Cssire�i � `A ' 8 i
<br /> *1tEiiti I Other 1}! a �Oa ,ype0>tCa�tlftg1
<br /> ;VIP,tie o: 1 •E k }n. g'*t ,-;• +:, a Alt
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<br /> rion Apprax ?' ❑Faslane Specificat ans Nk-I� � 31�-
<br /> pDepth 1 r Yin h �nxW
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<br /> aiaait )►ivtectton r Depth.of 1i1bSILSaa1 qqh yak, t.
<br /> Sa it sli`al `� S; k Typ lv%r6rout t
<br /> f- 3•wit Q ti^ + �`s O a t'�. 4 5 �+' xwZ �.ml h r•
<br /> Surfiie,�l�lnbta�iMd;�ar��:`�.is `
<br /> i r)riDtltFe }: Type of Pum P: 5taEa`WMrk ObiFa+t "�° '$ C €
<br /> D 'iietlon
<br /> 0! Well blaretor' i,Sea i 163 Material (top °rQ'�'f yf}T IS ` � •` ' r rte} `
<br /> F ., Depth• r C� i ,.`^Fi11er 14terial (Belay a4r l�,w "'
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<br /> tl 0't r rw, tF the 1f-oabi leneM�j"iS<�'
<br /> SEPTIC WORK: NEW IiWALLATION ' MA1RIAMITf0>t {No septi tank or teep 'PIF+ 14ttHtla�R ROD fe+k.)
<br /> r' taan will
<br /> ..rye:a Rasldierice ;�Ca�lierCiai ;�; other
<br /> ing units: "RUND 'pf beth WMK ' ..�. Lot 512a y a it
<br /> s r,yra,a*, i 118 b�i dtiptli
<br /> EhititC er�r,iotl tc a depth,of•3,tdet aat.say.. r.tv3 i�wtx 'a 2&1,
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<br /> �n �SyT.I�tM�}y1;�� NQlftanCll';'�'Y1Nbr!!<t �1�11 /��3,�,+'TOdA'Qatiolf��i� �^l�tr , � �+�.r
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<br /> L4S,1Vn
<br /> DE - y 1
<br /> ' ti --_DiatanCil It* rlat 'Will' � ; Faundationtar`� p! ► init ° ) T t
<br /> PUS'. nepth 4�;� r _ t Site
<br /> `!yjpwb AMD {Oisten a td hearl�C' I'All }ma k Foundatlan, ' " +1-
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<br /> x ':� ms a a a2 is
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<br /> 1sEr i,Lf3ltlfy that I have Of, �tadrthlt=ippliCaEiOe end that the wont Hill be Ivic" a n-,oaq°i rn
<br /> ordinances,•stati,:laws, and rule
<br /> ynd,rtgulations'of•LM►`San Joaquin local,ileilflr Oittfili:• �+
<br /> comer or.lieensed agent's sir.aturt certifies tWfdllewing_!,1, certify tMi,l lute bl b� twxn�f a-
<br /> 6r tM,�f f �ifomie,
<br /> 1 faiich,s
<br /> t4is_issued,.,I steal hot etol�y a++r-pertet+..in`such canner as +�i Secow�;latb3etS to 11lRtU>R> , xhe''+AsrV iiart�iLic .
<br /> 3 Co,atratbar't_hi�iit4 or sub-contraetiit9,tigit 1:04 Certifiits the folloafagt?'Ittai"tify tMif:ih;the ged'fo ` .
<br /> fl `chit rt•it V. awed. I 1 t aubfett to wori�an's com"diati laic^a �lii'iaYffia`' q r - *
<br /> C f rt Call r` i pinions` M+apTeUa driwln' oiY.ry ti `:m ��Q'�� ,
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<br /> tUSE ONLY `tr` •a � ��!
<br /> 3` 'l1'11- location Accepted by -
<br /> Mitddi tional Coo anents:
<br /> KtFz -Pic or Grout InspectionyF �`'' .f ..^�,"„Dat
<br /> e* •final Inspection by
<br /> ,Applicant - Return ell copies to: til th PenritJSerrlces 1li01 E,�111a2i11 } ,�•� �� , tib, > ,t
<br /> ;ta RECEIMED HY' ,r 9111E ,5 '}iNO tT
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<br /> j' , FEE BASE AMOUNT DUE :y �` A1101{NTREleIrTEO �. 1:
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<br /> 4444 t F
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