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—APPLICATION-FOR-PERMIT
<br /> SAN JOAQUIN LOCAL HEALTH OISTRICTa-
<br /> ,- ; b._tt
<br /> fr—HAZELTON=AVE -ST''pCN
<br /> Telephone {2Q9) 466-678f ", r""yy �r� ell
<br /> EXPIRES T YEAR FROM DATE ISSUED g dR �it
<br /> PERMIT EXP ,
<br /> x °f +Wompiete in Triplicate)
<br /> 1 APPhcetrl� herebY rrlatlBla the San'#
<br /> oaquin Local Health pistnct fox°�permit to construct and/or install-the wil erern descrrb .,iMs 8pP9cauon is
<br /> made in° ompllance vv�th San,loaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and R ulations t
<br /> Localp,{ealth district' r B9 haSara Joaquin
<br /> 4 ft 56
<br /> low +
<br /> Job`Adcrass;` r4 s 3 u ,
<br /> City =Lot Size ,s - x" Sr
<br /> a
<br /> Owners Name *Addr'
<br /> t Phone
<br /> '
<br /> Contractor` �� ¢ �.� : _ •- �-,,_ � -°'"- �
<br /> IY
<br /> dress' x s - at License No. .. _ i'hones y.
<br /> 7YPE.OF WELL/PUMP -. }..A.NEW_1NELL © ;. ,WELL.:fiEPiACEMENT`© DESTRUCTIONr,mi �.
<br /> ' PUMP INSTALLAT[QN.� a.- n e ? ;*��, �; �- c,1A
<br /> SYSTEM REPAIR ❑ OTHER © � �` a
<br /> DISTANCE TO NEAREST.°_SEPTIC TANK
<br /> SEWER LINES rN., DISPOSAL FLD:' °� QRO�F LINE`S "# i Y f yaw
<br /> FQEJNDATIONd.---�- AGRICIaLTURE WELL ' .OTHFi_WELL 'ur r
<br /> i },< PITS/SUMPS
<br /> y y,. INTENDED USE TYPE OF WELL %L:'r OBLEMAREA :CONSTfifJCTION''S,PECIFICATIONS ¢ #
<br /> ©industrial `i D.Open Bottom ^k s ;'"t• i �`.> p
<br /> r ❑ Manteca Dia of Well Excavation pre at Well Casing
<br /> flj� mestic/Private ❑'Gravel Packer 1 #
<br /> r F 1 ❑.Tracy ,rType Of Casing ., a '.z i ta': s •,r• sy +t h
<br /> f` other '� `t „` y Speufr Atwns
<br /> T1 Public e
<br /> w - flta Depth of Grout Sea! Type of Grout
<br /> I;I irrigation "r
<br /> Approxi Depth l I= stern Surface Seal Installed
<br /> Repair Work Done r ❑� -Type of Pump r M ra ,r_ 1{,P, s '#
<br /> 1 A State Work pone K
<br /> Well Destruction ❑ Well Oiametel t, ?
<br /> { Sealing Matenal ItoP 50
<br /> iPa t77
<br /> Filler Matenaf'.{8810 }
<br /> TYPE OF SEPTIC WORK NEW INSTALLATION i l�F REPAIRlADDlT10N DESTRUCTION 1,I. IND se Tics tem ^�
<br /> # k' P Ys Permitted if public sewer is
<br /> evadable within 200 feet.} x
<br /> Installation will serve Residence
<br /> Ctxririhercl+_` Other
<br /> Number.of living unit Number of bedroot s i
<br /> Character`of sod to a t of q-feet: '� - ' �
<br /> p Y �. s r b4 u Water tabte•depth 3' k7 a I y
<br /> SEPTIC TANK Y�....f.:t-�a,..:s" �"'. -. k -
<br /> ❑ TYPe/Mfg " Capacity •` No:"Compadments' x~;r
<br /> PKG. TREATMENT PLT ❑
<br /> Method of Disposal,
<br /> Distance to nearest: Well Foundation µ Property.Line
<br /> x
<br /> LEACHING LINE
<br /> i C�"'`Nfr 8 Leflgttl of Gne�' „�• �'� - � ��,�, -.�• .- '
<br /> "Ttl length%site
<br /> L Distance to dearest: Well_ ' Foundation �°` Property Line
<br /> SEEPAGE PITS I 1 Depth s Size
<br /> SUMPS ' Number
<br /> L� Distance to neatest: = .Well Foundation • '
<br /> DISPOSAL PONDS 9 .;..:< Property Line •`
<br /> I hereby certify that I have prepared this application and that the work will be done in_accordance with San Joaquin'countY ordinances, state.laws, and
<br /> rules and regulations of the San Joaquin Local Heaiih.ptrict
<br /> Home owner or licensed agent's signature certifies the following:"I certify that,in the performance of the work for which this permit is"issued, I.shall not
<br /> employ any person in such manner as to txacome subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature
<br /> certifies the following;"I certify that in the performance of the work for which this Permit is issued,I shall employ persons.subject to worknl8n's compel
<br /> The
<br /> tion laws of California."
<br /> The applican ust tail for all requo* d'inspectioris•Compl to drawing on,r rSe side. �
<br /> Signed r q„ e d '-
<br /> Titl t, f
<br /> pate::
<br /> r.r ' - i- FOR DEPARTMENT USE ONLY
<br /> :•� r ..
<br /> a Accepted by S 4-
<br /> Application
<br /> ti Pit or Grout inspection by;,,,
<br /> `¢€
<br /> Date. A
<br /> y
<br /> a � ;s pate Final Inspection by Date t/2 '�
<br /> 4� F iy. Additronal Comments
<br />,1 C. 13 Stlt - - :: eF &Mt '+ f7f �-- tf ✓-
<br />�az 3� 466 678t� ;1� todt 22i � rC]Manteca u 8zi 7104 O Trac r r>
<br /> ,vx APP1iC8iiltf9tirm all copies ta.�Env1` ' ' 4 ' Y 835=6385
<br /> k ' y x z 3 f� , {orintanral#leetth annWSerwces 1601E Hazelton Ave P.O So
<br /> �.i r t .-- ` Ay�y; .. s x t, _ •. x 2009,tSIk
<br /> S 5� f..`,1p, q; a. �•.4���''�'� " ��f•'.' k���'-,+ A -[ x�Ss _ '.� S �"""
<br /> " p° ..rt"ti. '3s
<br /> 'S
<br /> z AMOUNT R[:MI7'TEO -
<br /> r , s�`.' ,a r CASH RECEIVED BY DAfE 7 +PERMIT NO
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