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<br /> d APPLICATION FOR PERMIT L; +
<br /> SAN JOAQUIN LOCAL HEALTHDISTRICTt t
<br /> #rh �rr[r r 1601E HAKE TON-AVE , STOCKTO N, CA ,�
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<br /> :�t +r en r n, PERMIT' EX01RESA YEAR FROM DATE ISSUED „ttt �5M, � �4�v
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<br /> Application Is hereby made to the San Joaquln Local Health District for a permit to construct and/or Install the work herein'd.tscrlbedr.,Thfs NOV �tifk3n'h
<br /> a�made In compliance with San Joaquin County Ordinance No.549 for'sewege'or No. t B52 tor'welllpump and the Rules and Reg04s110ns of the-San%voii$6 Z(4��"t,"+
<br /> .i t ' r�f_{qx LOc/l Haatlh Dlftrki -I., - r' / [�k rMr
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<br /> shy Job Address
<br /> W'.1 7-1 I /¢I K t� C,ryL".}�,. Lot$ite
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<br />` ��,1,�•Owner#Name�- � ArQdress •��'��+w� - Phone
<br /> ih�r� €�'s L h,r M1 �. v n a ., -�y--;.. 7 r•, ,, �.,: :- J y K.�1I�,;+�h��,,���rl q��f}��C'i4�d���` r� �. ;. -
<br /> o Address � .�Sy3 s _Lltense No,
<br /> tie r' ;TYPE OF WELLIPUMP:' NEW WELL❑ WELL REPLACEMENT❑ DESTRUCTION ❑
<br /> a PUMP fNSTALLATION'❑ :"SYSTEM REPAIR L7 OTHER 0".
<br /> 7
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<br /> DISTANCE TO NEAREST .SEPTIC TANK SEWER LINES DISPOSAL FLO PROP.'UNE''r � <3��h���i
<br /> FOU140AT10N :AGRICULTURE WELL OTHER WELL PITS/SUMPS z br
<br /> rt� IMTENDEt)USE {,TYPE DF;WELL r PROBLEM AREA i`CONSTRUCTlON SPEGFICATIONS +
<br /> Manteca• J Bra of Well Excavation
<br /> i fp'�i ' brpo asS�elPrriateS i ❑'Gravel Pack ❑-.TracF % T pec cations`t3`�4mntTf` �1
<br /> a 4 Y Ypa of Casing
<br /> f iFAr`rblrc ;t Cl Otlrar fl
<br /> Do to Oaplh of Grout Seal Type a!Grout *ha3 'r7f .I'
<br /> r y t I InigatlonF;rk r '. 4 Apprex Oepth v l 1 Eastern u i 3uif' a,Serl tnstallad by l,'' aL ti 1 it t'
<br /> y �, Vee f IDestroctlonne C 1ket1 p{ramatapr .'•*._, 1 .,g P State Wdrk Done ' f'
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<br /> !y•� eatlng Material(top 50 I },Y r
<br /> h ril:s � ,a�^�Y?* { 3i Depth: n : -• +Flller Material(Below 50 i � 'r �� .+,.* �At ' �`moi' 1
<br /> tTYPE OF SEPTI�CjWORK NEW INSTALLATION I 1 REPAI ADDITION DE-,TRU(-.TION TION t I•INo supticsystem permitted rT publrc'Sewer{If7l
<br /> t Sir ,yy,YY�� fyWyevadable within-200feetlr }1iyrsF }�urRy.'71"
<br /> ' k!,Mtal T.L wiipserve'�Residence r hWm erl:l&I
<br /> x.; ,+ r u �J b'Th�t�&�_ ixr�,.: o .115L�'"'9t tier Jr.� �'r {• 4 fa t + r
<br /> �„ �� F Numberif'Iv�rrg unitsg.,,rS"Number;af bedrooms � � 1
<br /> "c
<br /> '> •r Characler nt soa to a-dapth_of 3 feet yr Water taWa depth { r+ ,
<br /> r �EPTIC TANK; 'I r 'I `r❑ T' /Mf „'' Ca aeny--"" No 'Com rtmentsv
<br /> {�, a� YPe 9-_ p pa a f FVi�k11
<br /> � a?+�s1PKG TREATMENT PLT.C7 a a f Method o[Disposals'
<br /> Distance to"nearest Well `Foundation Property Dns n b r +" y
<br /> r.y}c r r"�: u:;♦S15 v n r Y :r ;'. At W 1+ r ry s}�'1 *{rl IS,
<br /> LEACHING LW'd, �T'-i Cl Nor 3 Length o!Imes z Total lengthtslze
<br /> "5' l' u z ' + t'�❑ :Distanci tolnearest ° " Wellt Foundenon ` Pro ' Lini n " t� �r
<br /> FILTER BED �1u�� ;, f Pe+TY -�( ,t"i9?l,ll+
<br /> },1.�p1 �t"�ll rr^�n: 1 }rfiri-1§4 r7 L,�,h'�ilrr� r
<br /> i� - s'{ s r _ ;} •r rty J.-. ,. 1 i�'S 1 } i =
<br /> x 5EEPAGf:iP1T5 ?t� 1 t Depth Site a `' : bar-^
<br /> 15 SUMPS'Y t � �' " DKSapCdSQllOaresl Wall? "`
<br /> Property lme
<br /> All
<br /> of DISPOSAL":PONDu : Cr,
<br /> 3 t hiraby csitlly that I,hdvs prepared this;appllcation rind that the woW will be done In accordance with San Joaquin calnty ordinancei atato14A si il4
<br /> ruks`'and'reg.uratiorts"Suthi,.San:Josquin Local Health O3triet.e • + ,�; +�w',•' ;,4',•y a „
<br /> y 3 F Hans r7wr,w I"rel"ayent's;signaturd certifles:the lollowinp r eertlfy,ihet'in the peAormance of the"nilL or;'whkh'this pormit is(sued A ihail rtiottv
<br /> ,raxttploY any peisoF*i in weh rttennar as to bseome wbjriel,to'workman a-compensation.lawi of Geti[ornia ,,totitri6i6es.hiring nr'wtrt bntractkq'slgnaluai: {
<br /> li teAKW dM 16Uowirrp`*11 eenifli,that rn the performance of the work for which this permit Is Issued t shall employ persona subtest tow'&&man s compnn'asaYGa;
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<br /> vP„ r Signed Title !� Date
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<br /> USE-
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<br /> q APpllcationy Accepted by= Date Area
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<br /> �� v�, tP.�lct`pr Grout Inspection by Oate'�' / Flne!inspection by'' ,^ _-Dat>M t [t
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<br /> a AdditI64v.Cor;n nta /
<br /> t' °?+t ❑Stk F166g7gt rrr' Lodii'369-3821'< 0Monteca 82371 r O Tracy,`83S-6M5
<br /> r,1°5�1 Apptkant R_ aturn all eopies to Erwrronme in Haahh PermltlSarvices 1601E Hazelton Avs P 0_Sox 2009 5tk CA 95201 a
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<br /> FEE AMOUNT DUE "AMOUAT AEMITTED RECEIVED BY '.:DATE`•6 --PERMIT NO
<br /> INFO J -CASH
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