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<br /> APPLICATION FOR PERMIT
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> 1501 E HAZyL s OIN AVE S T OCKTON CA
<br /> Tele-1-cne (209+ 466-6781
<br /> PE'tMIT EXPIRES Y YEAR FROM DATE ISSUED -
<br /> {Complete In 1,q flcale) -
<br /> Applscat+on m he eby made to the San Joaquin Local Heahn ter^ ,cs for a t ;nit in censstuct and or install Ilii work herein des+nt+ed lits application>r
<br /> made m,ornottance w th San Joaquin Coonty OrcM3roCe NO 533 for=ewarf or No 1963 Tor welt,pump and the Rules and Regulaw ns .a the Sart Joaquin
<br /> Local Health Distyri/c�t
<br /> J]b Address Lct SrzB '2i-yPM ----
<br /> Owner s Nair e �_ra- CA --- Pno+e
<br /> Contrac or s Jame Lam, -`Q LlLenSe+.fc -`3 �- _ _ _ f ho"(.
<br /> TYPE Of WELL/PUN„' T� NEW WELL WELL REPLACEMENT DESTRUCTION �� G
<br /> --PLIMP Ili:T-LLATIGN=- SYSTEM REPArr OTHE"
<br /> DISTANCE TO NEAREST SEPTIC TANK SE"/El LINES DrSPOSAL FLD PROP LINE
<br /> FOUNDA;[ON _ AGMCULTUnE WELL — OTnEH WE_L,--_ PITS SUMPS
<br /> INTENDED USE TYPE ro-WELL P11p3LEMAREA CONSTRUCTIOv SPECIFICATICNS
<br /> d — - ---- - --- _l�-
<br /> Indusirsal :ape, Bottom Manteca Oid t+f V.eSI Ex Lr VdliOn _� �-t I Dro of Well Caatrty
<br /> Dcmest+c/For)va^e Gravel Pack T acv T%pe of Ca-uTg _ j Cy,L _ Spoci scat c u
<br /> Public = Other Del a Dnnth of Gfqut Seat _,;Z,y -t of Grcut
<br /> Irrsnauon Approx Depth Eas ern S.rtface Sur. h s a11cd by
<br /> Repair Work Done Type of Pumn __=_ =- H P - = State WorF Done
<br /> Well Lestruttior Welt Dramcter Seating ^Iatlh+i t Of,59
<br /> Depth-- F Iter Y1tt enal i Below 50
<br /> TYPE OF SEP11C Vffiflrc NEW IN5TALfATION REPA111,ADOITION DEST11U1'i 11 ��,rO sr ptic ,yS a,r permitted if public sewer is
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<br /> aval,rble v.,rom 200 feel I
<br /> n wi31
<br /> t Instaltaticserve Re _ 4 iderce Ccmmerc,al _ Orher
<br /> Number of living units ____ Nt. fiber of bedrooms
<br /> Character of soil to a dei.*^f 3 legit _ _ _- - _ Water table dent',
<br /> SEPTIC TANK TypL- htfg - - -- Capacity - - rda Companmenis -- - -
<br /> PKG TREATMENT PL7 Method of Disposal _ I
<br /> once to .,,,es, ^ail _ Foundation Prope^y Line
<br /> LEACNSNC LINE No 8 Ltngth of Imes _ _ _ w T,ird1 lrnntl .,+za
<br /> FILTER Pfri Distance to rearast Wet 1To;)Lrty Une
<br /> SEEPAGc°ITS Oep& -_ Size _ _ Numc-r -- -- --- --_ --- - ---
<br /> SUMPS D.s arre to r,,dro ,4`1 Fd„raxjc,n Prdo�r^y Linc - -
<br /> DISPOSAL PONDS
<br /> I hereby certify that I `saue preoa,ed Thos apyl cat cr dr,r+ tt,st iii, n- tiiii DN dune r r.0 7rrtj„ce with Sass Joogwr co ir+ty ardmanCeS state taws rind
<br /> rules and regulations of itie San Jcac;jir Locel -rdl h Pi c
<br /> Noma owne or licensed ag3!nl n sinn,ture certif,es thi r mr,z,nq I r., toy `at m i t,r,rr^ i ianc--,f hi nrk lnr wh+J, this pe mit i issue) I shall not
<br /> employ any person in suc`i r^.rnner ds to b,-corne i.aec,to r.,'_,r r s _ e,xn� m Id,n s of California Contfoc or s h+ring or soh Contracting signature
<br /> certifies the I^Ilowrng !certay mat,n rL perm mance n' h_,r tK f-r r hicn nit pt nn t i„ surd !shall employ arsons subject to workman s cLmpansa
<br /> tion laws D) Cafllofmk
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<br /> The applicant mL can for al ii��Iq\uVi11Pd insprctrons CumO3el�drdwing i- rt„t!�- we t Si nod X_ L ;'3 r
<br /> r FOR DEPART%lEj+LT USE ONLY
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<br /> APD1,rat.on Acueptad my - -(.�-�r ,/'s�J �] Dot- � � -'"�A”.
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<br /> ai or Gout,ns,,Pc io't by `De nd' in r� ,af by / ' w-"�� DaW
<br /> Additional Cnmrnents
<br /> Stk 466 x-781 _ L,-4, 3139 302 an ca j..3 7 y35 frMr,
<br /> Apoicd^r Re-urn all coaxes to n rronrt,rn, -r„t P, i SiA a 0 Pu. liV3 S 1• 9`9;701
<br /> 11r�U ! AMOL, "Jr- ._ ” -+ I _ f Nr r rr , ? JA k -� VENFItf NO
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<br /> Nil
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