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µ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E HAZELTON AVE STOCKTON, CA <br /> • Telephone 12091 446$J81 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> iCompleie in Triplicate) <br /> AOPkeatton 19 rw*tW meoe to 111111 San Joatlutn Local Howth Dietnet for a psrrr+n to Construct artdror etatoa the work haran dletnbW Thre aooacatton u <br /> made in eorwWlance with Sen Joboaw County onwianee No so tar nwwspe or No 1062 for weed Dufnp and the Amos and Regulations of ttte San Joaou+n <br /> Loci Health District ae �1 n 1 f /- <br /> -ti Job Addreoe ..7.Y [.,Jr.S lA a? .`I Gc.4rT 11 L, �( �_ � �7�4/�city � 0 <br /> �^ city Lot Srss a e PM <br /> Owner s Name 5+ I Address O Lx `I90Z 7 rt Dye �` Phpns O <br /> Contractor 4Cte a Address P.a &A 43C 54A"d CA-License No 'lsyoo Phoneq'K-W-0-910 <br /> TYPE OF WELL/PUMP NEW WELL A WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C3 OTHER <br /> DISTANCE TO NEAREST SEPTIC TANKt dy� SEWER LINES DISPOSAL FLD PROP LINE JW <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Indtuntat <br /> f ❑Open Bottom ❑Manteca Do of Was Excavation Dia of Well C.11111" <br /> )!c <br /> xGraval Pada C1 Tray TV"of Ca."-!kAlld qp eyf Spa dirawm �CC _� � <br /> I" Pubbe n Other n Oeits O"th of Grout Seal Type of Grout lLL�L tftr_ in} <br /> + + Irrmption z/Apprea Depth I I Eastern Surface Seel Installed by AILI& 4tl <br /> Repan Wert Dona L3 Type of Pump H P State Work Data <br /> Wall Deaauetion C3 Vol"Dtatneter Saa4ng Material(top W) <br /> Depth rd FWw Matatal 18otow Eff$ <br /> TYPE OF SEPTIC WORK NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I IfNo meow ayetotn permitted d pubes:sowwer is <br /> avwkbb wohlll 200 foot I <br /> tnataaauen wt$serve Residortoo Comitarcnd_ Other <br /> Number of swig ting" Number of badroorm <br /> Character of tad to a depth of 3 foot water table do" <br /> AEPTIC TANK C3 TW*jMfO Capscm No Corti*& anea <br /> PKG TREATMENT PLT 0 moor"of OMPOSd <br /> Distance to new= woo Foaaldatmn _ Property Lam _ <br /> LEACHING LINE ❑ No 0 LsnffM of hies Toted IsnWAIshe <br /> FILTER SED O Owalnee to fumew. Well Foundadon Pt+aps"Lmtm <br /> SEEPAGE PITS t I Doag1 _Siaa Numbw <br /> SUMPS L1 Dietatlor to nostaw was Foundation Prop,Lina <br /> DISPOSAL PONDS ❑ <br /> I horMly artdV that I have psepwW do apprlaalkp&W thea rho Wolk wl$be Ante to eCCOrdatlp vW0 San Joaglan CwiM ordbtareoaa,urate laws am <br /> fulaa and re0gla iww of 04 Sen Jtsagwn Low"saw Who*0 <br /> w Home owner or aowded apaltra$hl oatYEaa 00 Inan - n� I cwWV that in Mia paflarRlanae W the words for MAddt 00 ptllttUt is dried I alta))not <br /> 6014110y any pe=w in is 1dt trtart W eta 101 ,x a lta 111111111011111112 le vv aeon a a 0111rl—1111 lows at CMdlartia"CantraclWes hftV or 69mmum <br /> C@rWm Of 1 1 CaaWV 11111111110 ftPwIsi mance of the wast for wAWd1 d w par. ie 80MIN.100 aat40Y pmraotna ad*=ore workman a eomperwa- <br /> tion Is"The apoft 1we r 48 WN1Nlapaetlarte Camosis drowinp an rowaraa ludo <br /> Swood Tura l$vtt�.•-�oR (a@, pOW <br /> - I%L18r q a s / %w-kV-4 FOW 06PA MMT g 11 ONLY •, <br /> App$CWm AuspgW by l ._ -- DM Arae <br /> Pit of OMW hlapeaden blv Date ftw 11glpuCd,q bw one <br /> Adidldar101 CgWdMpltm. <br /> O Sd11 4831-M O Led 303=1 O M6411111111 1 dell 0 TMV 0364 i <br /> VNMM Relw11 N 0011 am to E/1Mrar1ttlanaal lr880 POMWSwinim 1811 E "aRatttin Ave.P 0 INIa 3M SdL.CA IWI <br /> �k" AMIOUNI OLIE AMpdINT N$MITTEO CASH 1112 ev DAT$ n MIf1 NO <br /> . IN tial low t, 11 <br /> r taI61 <br /> • <br />