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APPLICB, l�lhE' nQEpM�T. <br /> SAN JOAdUlhf 4C 1 '. 1A0H"618TA1Cf <br /> PEAMIT €XtW <br /> � . tC661p injupi:cate) <br /> Application is be+eby made to the San Joequln Local Haslth District for a permit to construct and/or Install the work he4a iliscribed.Thle application is i <br /> q <br /> made in c04npliance with San Jaaqulrf Gdti'nry Ordinantai No.549 for aewaoa or Nam 181 for vvellYpump and the Rules end ga{pallltiorts of the San Joaquin } <br /> Local HeaM District+.: <br /> r <br /> Job Address • City' Lo� PM ` <br /> Owner's Name .� �' AC't Address 1! 7 SD .' l�)s Lei. ('J�. I,ortao 4 �' t <br /> A. <br /> Conitattar t4 f/ass iE!#nsd <br /> TYPE' f WItLVPUM. �.: WELL E L REPLACEMENT,' D DESTRUCTION D ►-. 9.. � <br /> r1Ys��tlo �� ?1 first +#t�s:i►Arid w. .or a o '. + <br /> DI$T�k+I �TO I�E,�1lwt�e,� ,�EPTIC NK SEw ii DINE �r bISPO$AL::OLD-0---i': F'R ' <br /> ��y ;, <br /> E6UND ?3f#1CULt0F1 W5LL OTHER'WELL PITS/ <br /> INTENDW USt TYPt:.OK Af$h �. flail ArasA tbNSfAu_ 'TION SIiCc!�ICA oN s <br /> D IndustrIM <br /> open Bottom Manteca-. E3ia. of WeS>`icctrvatian of W e <br /> -n Donwmic/Private D Gravel f ek,, D Trac <br /> ,,,... y Type of Casing: � ��p : �;r 9pPEcl� <br /> l'1 Public I-7 DOW f fl DeNa Depth of Grout Siial (br ut <br /> �[tnigetion pp Surface.Seal-Installed by - <br /> '��A . rort.,t3iipth l 1,Eestetn- N44 <br /> Repair Work Dons U Type of PuAtp <br /> Will Deetructlon. Q i r Sealing Material f <br /> Dep . Filler Material;l <br /> ,,i.VFE IC.WOHK: N W INSTALLATION I1 REf A1R/At3 #TION i i �pE8TflE1 TION i I�INa.ae tib to mitt I <br /> IN <br /> wfilkv <br /> Installetion VAN so ftesrdance, . Commers! 'Othsr <br /> Number of living uni Nu .�! �—r" � : <br /> _• mbat`Yifi 6adroofne ;-' 'T "`•' <br /> 'i Character of ac#I 111-A th of 3 to&., Wster: l <br /> SEPTIC TAN type/M#g apacky_ N ' artriirrlitly `e <br /> ,PKG. TREATMgYT .C} "s Method b#' t <br /> " " + letened to Fdu atioh Prnpolty.Lir$E <br /> z + <br /> A: <br /> ,. <br /> 1 ,LEACHING LINE � 0; l+l a Lbngth of lirtee Total I#Ingth - <br /> �_ FILTER'SED �, .D D to nasrestf ' � �de1t4k1lYtkin . : pf�p�l�i fins - ;� � <br /> SEEPAGE PITS .11 Depth` Size Numbdr <br /> SUMPS Ll Dista to'riaarast +'t, Wap^ Fountlatiof '* ProWly Lina <br /> DISPOSAL POND$ D <br /> I hereby Certify that I.halve lStipafed <br /> applican t" that t Work will be dotte in l s Mth Sari JoagtAfi lGunty brditaneft, state lam art <br /> l rules and regulations of tits•$an 10 flea#�DIbbict <br /> f, <br /> Herne owner or licensed epent's flag ttlirtf�dls the foMtawing. "I ebrtify that in the W"iv'ivhlch this P01111.ii issued,l rl�il <br /> employ any person In Wt h Iflartrtar io l5et:W4 *t to wtxkman's borltpansatior► '.'tonbadtte"s hit, of tlul alttractir41 61tur6" <br /> certifies the following:"l Car*that i 19W10006w%�ir of the work#o►:wh 11r 1 ttheN <br /> tion laws of Gsliforn ; d t :• t rtnpltll+Eserionil eubjact to workman's et>rnpsY <br /> �. <br /> The applicant mu rjpt+et drawing bn 1'evb <br /> Signed tie: bate: <br /> it'At <br /> i 0a1% DEPAMM110 lU lel <br /> s a <br /> Application Accepted by D is i 17 <br /> Aram <br /> 0( <br /> Pit or Grout IntpsctIon Date Y_' Inal it petits l <br /> Additional Comments. tV t+o'44 tSki <br /> C. GaC.'104Hrt w. "} <br /> D Stk 466-Mi ©i odi:-:3WIlViV f�taflteLe t ( T q W, , <br /> App4icant Rrtet,tn tial t t�� fh+r�mtatl HaeNtli i�.€ senr nn re 6 Banc OOS� S tsCA'"I ` <br /> INFO "FEEAMWNT f UC— "`',iiA7lt`fl WR1:16I1'l'i'W. CAS R EIVED BY-7 pAii PERMi7'NO. <br /> Al <br /> EH M-2e / <br />