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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.TON AVE., STOCKTON. CA. <br /> Telephone 12091 4F3 6761 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplate in Ttiplicatel - - -_ --- <br /> II At'P•+.Mo n Iw.hy made tp the 5. Jnwrnnn l o,eI IE..hh D91,.[I f,,,•Damn 10 rnmTmct.I1d IPr wnull the wDM1 hara4.deacr6rd.I"apDlkwhth IF <br /> P med+.rm.n+,n.rn with S.n Juana,n I N Ordn,.nrn Nn !.11 Ind awwepe Or Nu IIA.21or wwNpumP.M th.141,4a• :RaP,M' m of 11r SIm Jtrolun <br />,1 Ir„ P IlNtrh(lgDrr <br /> JMr Ada.... S FO N h4v'y JY_... —. _--_ _----_ Cnv__S_ZTLJ tnf sits 1S`�SS_ PM--- <br /> �ynrn3r <br /> I Ow.rr.Nam. SFCCKTt'Fc1 aNur�G N. Adam» ¢l.//. U/tt/NADO e ._SF7vJ Pnnrr <br /> 1 <br /> [y,lrat hP ELQYF_i._.W nOD.--Adnresl _Z.N;.A QG(.4 A 0.rt�G—UErme No. .�17:Jr7S___Phor•a .E/6 f 79 T/ <br /> TYPE OE WFII,PTJMP NEW WELL I I WELL RIPLACEMENT i I OFS11RUCTION 11 <br /> PUMP INSTALLATION I J SYSTEM REPAIR I I OTHER (I <br /> DISTANCE TO NEAREST: SF^TIC TANK SEWER LINES -- _. -__ DISPOSAL FLO.__ -__ PROP. LINE _ <br /> FOUNDATION AGRICULTURE_WELL _ _ OTHER WELL--- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1'A d. mat t Open emlom l I Mameca Ole.of Wax E.ravahon _ Dr.of Well Calling <br /> I I D.4 I.c/M4a4 I I Gravel Pack n Tracv I"of Canng____. Spwd.cationA <br /> I Ptrhac I l OtM' I I Call. Depth of Gann S.AI -_.____ Topa of Oreut <br /> I I Inrpatm .-- Awo.. Depth I 1 Eatem Solace Seal Inalaaw by <br /> ORow Wak Dona I7 Type of Pump If.P. ._ __-_ Slats War:Done <br /> Wall D"Inction O Well Diameler Sealing Material Ilop 50'1 <br /> Dpth Filler Material IBalow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIOA I I REPAIRIADDITION DESTRUCTION I IINo Mnr�.yatem.pnlRliiD.'E it Pudk wander As <br /> T\,4b4 w,ttwn 70 Int.I <br /> Imtaeetion anis serve: <br /> Residence— fwnmerciel__ OtMr 1N�Ld•S/f'J � r <br /> Nt..bw of*vim f Prof s: —12-- Number of bedrmms -- <br /> Charaetw of sop to a depth of 3 1.1. W.Iw table depth <br /> SEPTIC TANK LI Typ./Mfg _�X-I-STJNry Capacity No.Compart.11, <br /> PRG. TREATMENT PLL CI Method of DfaposN <br /> Dlosoce,to rraml: Wed Fourdalim __. Pdpperty Line <br /> LEACHING LINE G✓ No. A Lenplh of hoed _'Y�Oy1_4f__L'JI__ _ Total <br /> FILTER 910 CI Distance ro.1. Wrll Fmrtdmlon Ski - Property Lar__i•_ <br /> SEEPAGE PIIS I! papth As' Site _�f =. _ Numhar <br /> SUMPS I 1 pletanca to rlM,vst: We" ._[GO—'. Fpunr)winn Proporn,LM...L_— <br /> DISPOSAL PONOS n 644c _y <br /> I Mreby c •Y,loi I fVM pnpwad Thio application and that tlr work wiN M done m accotdanca wllh San JoaauM ewDuy,ordea;heea.Item taws,and <br /> rues.n ral"tiw.e of the San am JoaLocal Health DANK. <br /> Mowrrr. nsed aggro's sig"I"certie4 the followioif "I Cwlify that M tlr w IOrrr,ance of Ilia work for avhch the pemtl <br /> ura a lice <br /> t a 4anrad,I ChM m1 <br /> Curb,wry prem M such manor as to bac n eubwt to wr.krMn'a comMnaal.taws of CeklwrJa.-Contractor's hir rp Or Orb—Ilftling slpnwure <br /> pniRaa Kr falowi`g:"I nrtlh that M dra ywfwm of the wwk For y h this perm",le Maud,I Yrs employ parao'r atrblset m wAi rkntan t av� <br /> tion hsr of CaYlwnle." <br /> The atrPRerR maw CA fa a re 0—d MpecWolf.Conder;d w A g on ravaroe ayMa <br /> shomd X— a(LRaQtAAJ ,, Tar: _(d/E�et - — ante: 11 2_YL <br /> FOR DEPADTTRENT USE ONLY <br /> App6Farbn Acespred by �O vwk r •"- ---- --- Dao Am � <br /> Aida orad lrrtPaeH.At by Dao Fires!Irtapectbrr by Om <br /> `y7_z <br /> Addrlanal Cerrwtenn! <br /> U 6a 4polml O Lod 769,3671 O Mantes 023 TIDE I]They 676 aIle <br /> ApP6ertt•Mahlon M Caples to: En.vcntrnlN Health PwmN/Servkea ISM E. Marathon Ave.,P.O. Boa 2006, BN.,CA 66701 <br /> q! AMdtrINT Wl AMOUNT AEMn1EDC H AEON rlp aY D tL "Plan <br /> .Ea li'C%/I/ <br /> w 1 <br />