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APPLICATION FOR PERMIT
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> 1601 E. HAZELTON AVE., STOCKTON, CA
<br /> Telephone 1209) 466-67Eil
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> (Complete in Triplicate) 01; L)
<br /> Application Is hateby mads to the San Joaquin Local Health Dlstnct for a permit to u>rurtUCI end/or install the work f.erem desenbed. This application is
<br /> made to compltar•ee with San Joaquin County Ordrndnt:a No.!rig tun wwduj ut No. IM62 fur well:pump and the Rules and ReVulsuons Of the San Joaquin
<br /> Local Health Drstncl.�
<br /> Job Address 4L1&),5N� kc
<br /> iC)�t -LTYT� -•-- Ctoy .57��--- Lot Sue J PM
<br /> Owner's Name ' -
<br /> `�4 .. fdl>�4s___p�'�_.____ Addraas _� TL 7_41P_- --- Phone
<br /> R�charoE pvmp,�5 �•- 2�
<br /> Contractor �- '(��Zr,1l, _ Address`�7 1 J .?iJ- ,? 3
<br /> TYPE OF WELL/PUMP- `+ - License! No. �-
<br /> - W WELL ( I WELL NEPLACEr,11i,N1 i i DESTRUCTION l i
<br /> PUMP ICSTALLATION (I SYSTEM REPAIR , OTHER (1
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES
<br /> - DISPOSAL QLD.--._-_-_ PROP. LINE
<br /> ------FOUNDATION AGRICULTURE WEIL OTHER WELL_- --____ PITS/SUMPS
<br /> INTENDED USE TYPF OF WELL PROBLEM AREA CONSTRUCT ICN SPECIFICATIONS
<br /> L I-Ind ualrlNl.l -
<br /> Open bottom (•i Manteca Ota. of Wull Lacrvauun
<br /> (I Donteetic/Prlwte 1.1 Gravel PockI I Trocy TY{w of Coauty -- Did. 01 Well Casing _
<br /> ---
<br /> I-I Public I I Other I I Oulu - Specifications
<br /> Dapth ul Gruul Saal
<br /> I 1 I Intyallorl _ _ Agates. Oeplh I I LtlYluuType of Gtout
<br /> l �... - ---. -
<br /> Repan Work Dom ,I) T `tuilacu Seal IllYlal)ttd by
<br /> Ype of Pump _.. _. .__ N P _ `---� --
<br /> Wall Destruction I 1 Well Diameter
<br /> !31.119 Work Ouna -----..---
<br /> _ _--.__._ 3r�nitn8 M01011.011110060'1 --
<br /> Depth I Icer Malunal IHuluw b01
<br /> TYPE O► SEPTIC WORK. NLW INSTAL LAI
<br /> 10N r I Irl i'4i11 .:UI1111fIN LWOW) i IN.)wgrht: sy►bm -
<br /> f fwtn„ituJ it puhkc sewer is
<br /> InslaMatan*1111 some: Rewlence avallablu within 2W fact 1
<br /> Clxrtrt►srctal � 0111611
<br /> Number of kvint;units. _ Nurntter of bedlwtnts
<br /> Character of bog 110 a depth of 3 leen - �-
<br /> SEPTIC TANK I 1 Tye i/Mlp _. _ Walur labb depth,
<br /> PKG. TREATMENT PLT.I I Caltucliy Nu. Compartments —
<br /> Distance to nearest Wan MoUwd of bl,Ktosal _.-
<br /> 1 ugtarlY .ntu .
<br /> LEACHING LINE No, i 1ng11h of firers ah♦
<br /> FILTER Oto I tT,tl.d IanUih/Ytru O
<br /> Dlsrance Itsrwwtesl
<br /> 1 n,thdalrm �� 0
<br /> SEEPAGE PITS tb heplh as r !ora /
<br /> SUMPS (G[ tr„n,l.ol ��,� . -
<br /> 1 DI►urtce lu rtearrsl Wen 1 `A I a,
<br /> rJISPOSAI. PONDS I I t I I,lenty l ma .�
<br /> ;.
<br /> hoe
<br /> oftily
<br /> .di
<br /> 1 les an cerin t,on 1 have h INry.uer)IhU applesaI-.n and Il,at tow wut► qui La dura ut w vwtLta o M1Ifs San,ludyutn cuunlY wdrtuu.oa, ►Iola bws, or•d
<br /> rubs atxt rraulabum of the San Juayutn 104 al 1•.allfi Utsu„o
<br /> v Home t•,.vrwn .•r licensed allenl's wpnrUtr,•,"Iotas Ilia IuUuw,n,l 1 rotUly Ilial ut tfsa 1,•ntumwn,r ul Thr wwk for which IfW
<br /> `"t• erroPlOy any person to surfs noam,et h,r,.tcwr,e stdtlrcl to wwsma c o .onq,ensaltntt Lrws ul Caldo"I I ' pwmil is
<br /> carld es the lullowtn "I y I goillued• 1 afsaY)lot
<br /> U cerUl Ili. tLo rrlotmauca ul Ilia wut►1,11 whH h Ihty Iwuntl is t►utal I►r all emttil�taetul's Iulr•y w sub Cw111ticlrvd alinature
<br /> stun best of Caldun,la" 1 Y{wtsc>ru a.Gptl W sew►rrurYs cwrgtraYsa
<br /> Tito applicant n nl call lot all res ons Gomlaoiu drawmy tet Inview►air
<br /> Stpne� J�^a. . . i?v - f✓� T,tlr n �..�►
<br /> Odle
<br /> to DEPARTMENT USE ONLY
<br /> Apn1t:ett in Accuptnd by _- t`•, ti \” - a C\ L
<br /> __ r
<br /> y;
<br /> Pot W Gruul Inslacbon by Aea
<br /> Wits //_ Wr '
<br /> _ -- - F,nol Insfwct,.,n by �•
<br /> A(udtbm
<br /> Onll Con ^lanls: _-..� t. I /_ p • f
<br /> b"r... t.) Sit, 466 6781 l 1 Lodi 369 3621 r : Mallorca W) 1lila3
<br /> Tlacy of fv3Nj
<br /> ApWtcant Rn1um oil copies to: Env,tunmrntal Hnulth f'atnol.Smvtcns Itt(1 E Hatailun Ave, P 0 Nua 21JOy, Sl►., CA 9h201 �.
<br /> ay '
<br /> 1
<br /> Jr, �''1-• ' INtO AMOLNT JUE AMOUNT ntMITIfD -{I KECLIVED by
<br /> DATE
<br /> r)N inky � I )' t CASH _' ___— ►EpWI NO •
<br /> C( ( �``y - - r'
<br /> ! ., /, C
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