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APPLICATION FOR PFRMIT
<br /> SAN JOAMAN LOCAL HEALTH DISTRICT
<br /> f 1801 F. 11117E:.-I0N )1Vf:., TOCh:TON, CA
<br /> T'eh`i}ho rttr {209) 466 PRI
<br /> f'11"I1 EXPIRES ] YEAR FROM DATE ISSUED
<br /> ICCrrrl)yh•,(f m InI)Lc II 3
<br /> f`PPIrl,rtlnl I; h,•r,:!ry mailL'to[rte S-11t Jn i y 11 ! al!L !I!1 Dei„w i,,1. in• ;%{I..111 !SI '.nr5.tr 1 t rllw Inst.,!t Ihr:w nl•,ern deer-Ilhl•d. �Jrls a{>plicatlnrr iS
<br /> mdrde!in rnr nl,harr.,:viith Smr Jr quFr!;uunfy OnIu I,In_ t !4 1 I I w,r,p:n,Nu 1;161 for well!p�ungl ane lire Rures deet Fie.,ula GOrrs of the Sm Ju,u,u�n
<br /> Local Iludhtr Lhsd.r.t.
<br /> JohA,lnress (Jt�- ,.-JL_l1/l } ” _ `f Crry&�_ Lot Sitr:!!" A_ PM
<br /> Owner's Nanm rbUV.�.__ e .
<br /> 24_7 _ LlC eflSe {,!J �4� 1�h4nnC 7ff1A��/O�
<br /> k.J
<br /> T)'P�OF tv£LL/NUM P; NEW wal- !: - V4I I,HILPLACEfMFNT I DEST)WC710N € I
<br /> _._._.�._....._...._._.._-...._- PUMP INSTALLATION E; SYSTEM J(FFAIR [1 OTHER 11
<br /> DISTANCE TO NEAREST; SEPTIC TANK LINES DISPOSAL FI D. PROP. LINE
<br /> FOUNDATION _ _ -. AGRICIII-TIIfiE WFL I OTHER WEtt. nf75/SUMPS
<br /> LNTENGfD USE TYPC Or VVUL ^140111 LrA AHFA'
<br /> CONST Rl1C1ION SPECIFlCATIDNS
<br /> III.-us[riol -- Iii _ _� _.._.._
<br /> f-iOp n Rullarn r Manlr•�;,r Dia o Well II Fre Ivuinn Dia.OF Well C.sin❑
<br /> L!DomesnclPrivatc LI Glavin Park €!Trary Type ul C"tsing __ _--__ Sp.-Cif,utiuns -- (-)
<br /> V! P01h., 1 1 Other I 1 O.;Itd Oupth M(,;rout Seal Type of Grout
<br /> - I I In qle l,nrr _.__ AppruK, DL•p Ih I 'Last.x r, Surlaw Sn,rl.Ins(al(ud b
<br /> Rep;:ir Wor}: Poor+- I II of Pump _---� _ 11 P. _._.�,-- --',Slate Work Done --_
<br /> VJOi Dostnn:Y.on f ! Well Diarm;trr �__.._.�-„--. S,:ali,lii Melena!1tr.p!,,wi
<br /> _ D,pltl -.._--_--_- f-iller Ma let-,11_1 Rvlo-50'}
<br /> I YF'E(1F Sla'IiC rJ E:W!PlST Al1ATlO ry Fi LIb1IR A;�[TI(1 f1ES1 HLICTION I I 'iMO s,:p rr[;system yt.nnq d:d it puh:ru•sewer is
<br /> available within AM feel.!
<br /> InSlillld lion will sC nrL': Rf?5111L`fIC},- Conyrwlrial—_ Other
<br /> Number of living%roils:_ ,_. Nllm11ltrz'(I1,�j_b,�e,c.n1urns
<br /> Charachn will ll to a depth of 3 Icut:, rt's' Water fff// table depth
<br /> SF.PYIC TANK y( T,,,,/Ml, _y(r'k 7sru•'s__,_ �_._ ity��Q�.-, _-_ No. COmpartmmrts
<br /> PK(',. TREATMFNT PLT. Cayr;,r
<br /> ' I I 1111 f Method of Diernsal
<br /> Digmnre In nee.eSC Well_l 0_.. Foundation PropOrly Line
<br /> LEACHING LINE No. &t.ungth of lines .._µ•_ i� _�Tul(il leinrlfh/siza_�V-.X/ ---�
<br /> FILIER RED 1-1 D: rW?iurJ
<br /> r•-
<br /> Fourufatinn.-..]�.—_.._. rroperty f ine.-y7
<br /> S5EPA(.E PITS Dayuh
<br /> f. SUMPS I I DlsuulcO to nearr.n.: V,rrdl. -/`�1 r' .._.. _ .
<br /> i-V� £'ounddllem `f/_.._.__ Prnparty Line
<br /> DISPOSAI.PONDS !i_ --
<br /> I hetuby carbfy I1ldt I havc pr(rPared this ap P!iralion and that Ilte work will he done in accurdanl;u lith San JOaquin COunty ordinances,start,laws,and
<br /> rules and regulations of the San J•,aquut LaCa:ylnBlth'Dimfirt.
<br /> Home owner or licensed agent's signature certrhu•,'tho lullnwno{y:"I cisifily that In 1lur l>erformanc(t o1 the work for which this permit is issued,I shj11 riot -
<br /> - + arnploy any person in such mapner as to becornu salijer.l to workman's Compensation laws of Cai.omrira.'Conlractw•s!tering or sub-rontracting Signature
<br /> ca-lilies the f011owing "I certify that in the porf ormanre of the wn1k for wtech this porrnil;s iSSLrod.I si
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