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e/ <br /> p j 3c <br /> APPLICATION FOR PERMIT <br /> q P' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> � <S Telephone (209) 466-6761 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is he'eb'nsade to the San JoaPen Local Health District for a peri R to coreouct andror install the work hnein daxrked.TMa epplfCatbn n <br /> Local Health District San JoaRun Counh Ordpnwrce No.561or sewage or No. 1861 fw well/pump and the Rubs and Regulations of the San Joaquin <br /> Job AddoA ��. / �J► / , sE •„ <br /> !s/ Cm 5 Lot Si:ef �r�J PMS <br /> Owner s Name bELAS �— P <br /> Contrxta _n#Q __Add. !�/,16L-S%j- License No. .41 <br /> TYPE Of WELL/PUMP- NEW WELL t i WELL REPUCEMENT L, DESTRUC LION LI <br /> PUMP INSTALLATION Z SYSTEM REPAIR (I OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK ___. SEWER LINES _ DISPOSAL FLO. PROP. LINE <br /> _ <br /> FOUNDATION-- _ 7—.—AGRICULTURE WELL OTHER WELL PRS/SUMPS <br /> Ir,t ENDED USE TYPE OF WELL PRORLEMAREA CONSTRUCTION SPECIFICATIONS <br /> . tndussrial Ci Open Bottum Manteca Dia.of wed Eacavatyyl_ pis.M WonCsarg — <br /> Do^+eniclPrivala a Gravel Peck irxY Type of C~g_— SpectRo none <br /> Pubic L:011ier "' Dern! Depth of Grout Seal Type of Groue <br /> Imprtgn _Apprn.. Depen Easrern Sudace Seal Installed by \ <br /> Reps.Wort Done O Type of Pump __ _._._._ H P. . _ _ State Work Dorn_ O <br /> Well Dean (.twttioWell Guanine, 5<aLrg Matetw Ilap SDI _ <br /> Depth Fider Mwerbl IBabw <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DES T RIJC TION i I INo MP1K system per idted it public sewers <br /> t, <br /> available within 1(10 feet.) <br /> Inetraopn..+a serve: ReydaKe _— I:amertw x- DOW.-`.��1{LlN <br /> wrea of ay.g nrrras: --- NwMer of ledrooms.— <br /> F/ <br /> tPTIC T v of aids u a deed.d 3 teen: .__-__ _. Water cable depth <br /> SEPTIC TANK ¢s'lypalMlL,�/� C `�� Compartments <br /> PKG. TREATMENT PLT Detente,no reareu: �VC Method of DisposNL-Well 4* �17 <br /> y_ <br /> _pE•L--_ ... <br /> •.EACHING LINE )( No.a Length of Ines `2� moi._E�aszFap r Total length/sin_ <br /> viLTER BED , : Deganre m rteaac WA r-__.__ FOurldatgfl_._.___— Prop"Line. <br /> SEEPAGE R � <br /> TS Depth 6�. _..-- T <br /> _- Sue <br /> ---- NumMr _ Z <br /> SUMPS . Disuncs to nssrese Wee -. -. Fandarcn Anpedy Line <br /> DISPOSAL PONDS <br /> I horelly certify WL 1 IWe yepyld tMy 8PP6CauOn and that tTe wwh coil t»done in accordance Win)San Joaquin county ordlnamea.51810 Tawe,and <br /> rules and regulln—of the San JoeoPg Local Health DetrKt. <br /> Mpme owner or kwoed'Pon"s sq.atwu cen to i the lOsowng '"I comfy chit in the pedormance of tha wore for which the permit is issued, 1 shag not <br /> onto"arw person an a..eh mane"into become sublect to wpamai s camcansstgn bws of Caldorry o-Controcfore hiring m wD contwung stipunge <br /> cantles de loaowrtg "1 certify that in the par`*`v arca of ata was 00r whKh tM Wn"it a esued.1 alien employ persons wbjnct to workman's Cornearee- <br /> ton br.s cal Cellona' <br /> TM apPaCa/nttmvust call Ip as r.quim! Comp�a/tg�awing revers!aide. <br /> Spred r�/.J-�� �F.!_ _. .. cr-. L- ii:b ..- - >�Tt--�_' <br /> FOR DEPARTM E USE ONLY <br /> / / 7 <br /> Applcaton Accts' by _.' _.__.- __ . .__ Dau_(=4_. /p Ana <br /> and -"1. __.__----_-- <br /> Pd w CVVt hgpec0on DY /in°a'i P^albwactfie?pYi`L <br /> A:.:ddrrventt <br /> So 48&67e1 : .L: Led, 369 <br /> 9362t }•sl MennN-�ca./ffi1�71V6_4 . TrairiMf %e-}'r,- <br /> ' <br /> Apyunt- Pettyn N coPao to Ei't'nmenw Heath PemM:Sidi 1001 E. Maranon Ave. P.O. Rai,1009,Sta..@:xil <br /> -CCA <br /> FwW AMOUNT WF aMOtMT•tiSnnED SM RECDVf0 f1Y DATE <br /> PERNn N0. <br /> l-Lv-Pa <br /> t-•ate O /CL <br />