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• APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON. CA ' <br />( Telephone 12091 466-6781 r' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> AO kMlotr is hereby made to the San Joaquin Local Health District for a permit to construct and/or hotel)the work lwairl dRwft in escribed,This Ippacatipt <br /> Local Health rotncOrs twith San Joaquin County Ordinance No.549 for sawaOO or No.1862 for wNl/pump and the Rules and Reputalore of dose"Joaquin <br /> Job Ad14900 W.dress Htr1► 12 City 22=1n011@ Lot Sit♦ pM <br /> .•t> <br /> owners Name Steve Woodard Address 14900 W Her 12, T erminel, <br /> Plowe ` <br /> Contrattor Asda Science Enttineeradmss PO Box 535 Se•+ 1+Ae�n., License No. 687000( 71vt...A. <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER V Boll borlag8 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD pgpp,LIME <br /> FOUNDATION AGRICULTURE WELL OTHER WELL '' <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> ❑Industrial ❑Open Bottom O Manteca Dia.of W111 Excavation - i <br /> O Domestic/Privets ❑Gravel Pads ❑T-cy Type of Dia.ei WN CA** v <br /> n Public n other n Doha OapM of Gout Seal beatocnitat oma . R J, <br /> 1 1 Irrigation —Approx. Depth I I Eastern DepthSwf&e Seal utSta w by Type d GwA <br /> Repair Work Dona U Type of Pump _ H.P. State Wotk Dona <br /> Well Destruction v Well Diameter Sating Material(top SO.1 Meat C@i111411 b@ntopto Ali* �. <br /> Depth. lfeet— Fill.Material(Solo,50.1 4 bent <br /> TYPE OF SEPTIC WORK7 NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION(I <br /> tnstapatbr►wpl fxnvs: Residence <br /> wapable wlthN <br /> Number of N pupae sewer b <br /> Commercial_ Other <br /> umber <br /> of bedrooms <br /> waehr of so/ depth of 3 fee <br /> Ct <br /> SEPTIC TANK O T / WSW tabM depth ' a <br /> yDe MIO Y No.� w .. <br /> PKG.TREATMENt PLT.❑ - <br /> Distenm to rearm: Wap Foundation_ �PMPWW LM �' ,$ , <br /> LEACHING LINE ❑ No.A LetrOth of Ones <br /> nol <br /> FILTER BED O Distanve to it&~! Wap Fowrdatlon Total Ropany LMIa 1' a <br /> SEEPAGE PITS I I Depth a•' r. .{ t ..:.:�. a, y <br /> umber <br /> SUMPS L1 <br /> DISPOSAL PONDS !a Oiaarloa to tlaaHtt: Wall Foundation <br /> t Ranby cattily the 1 hwa Pouted this a OkWon WW that tM work WE be doth M aocpdtrlp whh San tit <br /> rola and repubatiortt of the San Joaquin►Local 1MNth District. oalaltyandlAMtoaA alala.taMlAsled. <br /> .n a,•ro <br /> Hone owner or pcalteld agent's sipnatm cutifita IM following:"1 owllfy that in tM PwfomNnm of tM wak for whish Mia <br /> oa tlor <br /> etie tolbwlnp: o/tt y th/tallr�t a«fit to workn+an•1 oomparr/tion lyes of Callfoeda•' 1 0�rit k ilwta�.l.t>hB rot i <br /> Non laws of CapiarrYa.1' perfOfrrlallOa Of thN work for 11YIfiCh three panNt is baued.I shell employ man is subject to woo _ " A. <br /> , <br /> 11ta to for all irepationa Cornpiaa dnwirtO an fevuse eida.' •- . '�i�`N <br /> s319Nd Tea:__Envirg" Antal"88a&+ai±+« <br /> PARTMENT u>1E ONLY <br /> AppmA by <br /> e <br /> Ph or'Grout Inapaodlo by Data PNtM 1 bV37 <br /> AdNffon.I Corrwref tt <br /> O Bdt 4e6'Q)at �� ❑Lorlt Jeg•3521 O Mansel 823.7104 O Tracy 896.A396 �•- <br /> RatrNn ak to:.:rNkwwhw4M 1ISM Prat'11/840V6664 IMM E.Hanhon Ave.,P.O.Bost 200D,Slkt.CA E6i01 <br /> woo <br /> AMOUNT Out AMOUNT REMITTED <br /> M R[CEIVEO wI OATIE `PERMIT No. �' c• <br /> .atsaralev.,••.r � 1 � <br /> - �,�•. /909 �•?S�t' .? `_ ; I ., r�►.i <br /> .,•.•»,y�•.y,•.;....y;.,r.r,..wwihM. , I .. .,o M,a.r» r a -w.r.� �• <br /> n . <br /> • M Yll' M••rl•f: � 1 M• .. <br />