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APPLICATION FOlt PERMIT <br /> • SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1SD1 E HAZELTON AVE . STOCKTON, CA <br /> Tetrplh" {2091 4654FMI <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete In Trlpidcate) <br /> colic CO b hweb14MID meds to rile SM Jotaann Local Hesldl Oistrtct for a pemut TO COFNIMMt stw/a.mtoll the work herait dea6rib0d This ecoHeatwn m <br /> mage H SILK 1stnc wteh So to Jargeal Camty On*MM a No 549 for rwape OF No 102 for wsN/lILMM and the Rules wo flogLAattorm of the Sen Jaaqutn <br /> LOCI!Haak^h(]IltnCt 1 <br /> Job Add►pa� t1ef1 I�LC&Jw1IS..k� �•fnn 1� Cav fess Lot Sue 8aC• PM <br /> Owner r Name u WW Add►ptf Y V 2?ag I-AQ Z-4 :fin IS-ya Phone ' <br /> Contractor Addreal SPA n!E_'5&n I&M-1 License No 4S 220 _ phono ql ICO-1391 <br /> TYPE OF WELL/ UMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER ❑ <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES — DISPOSAL FLD PROP LINE / <br /> FOUNDATION AGRICULTURE WELL OTHER WELL UEA _„ PrMisuINPS <br /> INTENDED USE TYPE OF WDLL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 7 Industrial 0 Opm Battpnt ❑Manteca Dm of Well Excmmn Dia of Well Cal" <br /> a Dontsatet:/Privare ❑ Gravel Pact p Tracy Typo of Spftftamm <br /> Pubfte fl Other n Dens Depth of Grout SBM Type of Grim <br /> 1 1 Irrtgstton —Apprm Depth I I Eastern Surface Seal lmt~fly <br /> R"m Walt Done L7 Type of Pump H P State Work Darr <br /> WON Daabuctlon X Well OWn*W Seem"Matanxi Itop 50"1 <br /> OMM l3D' FRor Matwal IBaiow 507 <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADt)ITION I 1 OESTRUCTION SND saptOc sgntent parrrtteted d PA*c estop is <br /> av4dabM wrilm 2130 foot I <br /> Irotatlatton+�serve Rsladarlee— Comcrrnpal_ OAme <br /> Numbw of Nvmg units Nenram Df Mdroonw <br /> Clwwm of and go a doplh of 9 last Wasar ta01a drpeh f b <br /> cPTIC TANK ❑ Type/Mfg C No Coltwormiertll <br /> PKG TREATMENT PLT ❑ MrthoQ of n; I <br /> Dim to resomw WOO Wteddatlptt Prapmyty Lipo <br /> LEACHING LINE ❑ No G Loreglh of Etter TOW Ignp U <br /> ela <br /> FILTER BEA ❑ Dtrtllrtam to nearest: Well Faendeam_ Prepsrty Lep <br /> SEEPAGE PITS 1 I O"m SIz: Nss>Iw <br /> SUMPS Ll Oistanoa to fteaa6q� Wsf, �� #wtrtAadptt Plopaty Lim <br /> DISPOSAL PONDS 0 <br /> 1 hpobv at.dM that I hpMs III M=9d this SPI1111111111111111111110 41111101110 do wo*wed be dome al eCCgrdome via Sat,loagtm y ordird"No.at"testa, end <br /> rules and tagulatiom of tido Sal Jorgeit flail 1412211111 bb&kt, <br /> Homs owner OF NDNnaod a0mWo t11SIe m - 11 m On feretairtg:.y ewnifv diet M dw parforind age d do mark for tedtiell Ads pslattdf is OKI$ .I apes not <br /> u. employ arty Peraen p setdt ndplvsr p eltl ttsasftie tltAiaal M eralkrltarl'a norrpa+mwbwl krwa of CaNlaleill. Cart"a ws IYIIng or atft-centrat tse t spin" <br /> ��. ton laws at f attic. AM Or Mfr p1f101R1o110s df IM work fa wflieh Asia perrnk is rplod,!dtrB mRpOaV peramta to wortwrort s eompsnea <br /> The appNeam m icalb ss glpir/bldpa .Cdltlpltllo tlraerYp m ensues aide. <br /> Stgrrd . .�• Tlda vKe sfmftscgdaDace, �O <br /> ` t @i►A CI s i1jASi POW OEPARTMOM IN a fty ■+elk <br /> Appfadetl Aecaptsd I!y .....�..._. Dmta Area <br /> Pit or Grad htepwom OV Om 1 ar Oa® <br /> AdifkWmW Comffwna, <br /> D SAl 4084M ❑ Ladl 3W31Tt1 Q MOM= M7104 (]Trroy <br /> AaPI ne Rrhrrl ad caplet to embowwow Noah Pam*/BseMtaro 114M E Kanftn Ata., P Q So MD, Stll..CA I OR <br /> gas AfaptlNT OIAS A01pU1fT ROtIT►ttp CA>:H REC4tylta w DATg P110111 T NO <br /> aNtlaew4V t eu <br /> EN twya <br />