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APPLICATION FOR PERMIT <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT i(J' r <br /> 1601 E. HAZ Phone (209) 466-681TON AVE., TON, CA FryV/R�(/G �� 19 <br /> - PERMIT EXPIRES YEAR FROM BDATE ISSUED <br /> (CompletePERM TE���I(,C'c.�rL' <br /> ',. Application 4 hrebY m.G to tM Sp Joprn Lacsl Wahh Diwwl fw.Permit w construct.rpt/w mull tha work brain de.criMd.TIN,i�lk�^lefx>n u <br /> m.d.in compi.nce with San Joeol Counly Onlin.nca Nu.5191.sawapa w No, tBU fon was/Pump.nd IM Ruialnd Flnuptiwu of the San Jo.Ruln <br /> `f Loin Health Diankt 4' <br /> 00 Addreavfe 37� , MAG LiA_P� ESGO! Ai <br /> CKV Lot Sias_ - PM <br /> o .;1 N.ma AMRVIN [ 41do ins 51if P,,aM ' <br /> Lk<na Nai '9!fD Phog! — ' <br /> Il 9 <br /> . <br /> .TYPE OF WELL/PUMP . .; NEW WELL ❑ WELL REPLACFMENT ❑ DESTRUCTION ❑ �. <br /> ' PUMP.INSTALLATION)w SYSTEM REPAIR ❑ DINER ❑ <br /> " DISTANCE TO-NEAREST:"SEPTIC TANK''" SEWER LINES _ DISPOSAL FLD._ PROP. LINE'__ `sY <br /> FOUNDATION �AGRICULTURE WELL ---'-" OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS - - <br /> -❑IMustnrl - ❑OW Bot c, ❑Mmtaaa Do.of Wall Esowflon Duaof Well Casrp <br /> I 11Q DorrrnK/Prvsu <br /> 11 Go"Pack '` L,Trll y :. Type of Casino Swi&fidorr . u <br /> fl Pude ❑DIM( ;7 Delta Depth of Grout Seal - - Typa of Grout <br /> :i 1 I hrp.tron _APproa Moth 11 I Esawn Soda.Seal Mvlilbd by _ w <br /> Repaa Work Done ,�( Tyq of Pump �{,(� H.P. State Work Darr Zwa7All <br /> -� Wp Dptmctwn J Well Oimeter Smlinp Material Itop 50'1 _ <br /> " - Depth FNbr Matti IBebw SO) <br /> j TYPE Of SEPTIC WCRK NEW INSTALLATION❑ REPAIR/ADDITION 1 I DESTRUCTION I I INo s!Tm arum pn ranted it puM¢sawvr b <br /> t a adabb wrthln 200 feat') <br /> '#r ~''InstNutgn ail serve Resdenu� •ComtrrcW_'.Other - --. <br /> Numoer_of}Wq,unito;•• ':\,N9uo, rolhahaorrr- <br /> r Chuaax of.w to a depth of 3 f.ec <br /> /" ^SEPTIC TANK ❑;-T W+ter tai depth <br /> f' ype/Mlp ' - CapwitY No.Cornpanmonts _ <br /> -1 '_PKG. TREATMENT PLT ❑ Method of Di.posal <br /> Duunce to nes eit Well Foundation Property Lute <br /> LEACHING UNE . ,Il No 6 Length of bts - Total IgPoth/azi _ <br /> I FILTER BED ❑ Dutema to rwrst. Wall Foundation `Property <br /> SEEPAGE PITS I Depth Sia NPp <br /> r' SUMPS L7 Onu a to rw.aa Wap Foundation Proprty Ler t <br /> 1 DISPOSAL PONDS' <br /> 1. I lien,Rhereby petty Urt I of prari jo this 1pPk[adarl and stri drs wwk wltl M dory In accordartca With San Jopuin cw ty wderrrac,NY taws.�snd t <br /> . rubs and regulations of me.5m'"Japukr Local Health District. <br /> Home owner tt Ywrrad pmt's sionatun cartMee tM folowi g:"1 INat M tho <br /> k 1. asrtllY pen.msnra of Thi woA fix wtJch this pmttit <br /> is herd Istnot <br /> �.x':. eloi any Parson h arch Irrrrrf as to 6laorrr auhjstt b waknrn'a mnpentation bvn of Caldwtw"Conb,,,I f.hrn9 w arbcon u:e <br /> n nt,� osraKlai er fdloWaq:'1 ceNfy tMt M this psAonrrrra of tM work Iw ankh this permit Is rasuad I ahaY trctvp C <br /> 1 n tbn bet d CaWoma" aTPby Donau rubMct to workmrl s cwTpw u <br /> e ,. Tin t !wn - <br /> y xtn yaP{IkFJn raQu ,Cgrtpbt drawNq on navarp sWe. <br /> t A u 81WY0��_ Thk: _ <br /> De <br /> a i <br /> . ' . t ;_ J�j✓gC'4 _ pFORD RTMENJAE ONLY <br /> awl Aopai <br /> kf -� Pk e( 11np�ction W ' Dat_ Final lmpxoon Wyk Dzus <br /> �:]- AealuonN Camrnt: <br /> a�'�r�O Atk`•4fY-BTBt O LPN 3%X21 ❑Mantas M710E ❑Tracy 835403M <br /> .. AgaGCmt-Ratunn tl cods to E...... rn•,al"'i ParmR/San-iw 1001 E. HasMtan Aw.,P.O. ecx 20..'0,Srh.,CA Mn <br /> I ° <br /> INFO AMOUNT WF AMOUNT REMITTED RECEIVED aY T[ '. - 0Ml1'NO <br /> - <br /> laalunN <br /> �:--•'�°': -2tY:Z> Cap'A1t�!'4i+rwr.srrNvq-:.Yri�e�+......._......_ ._.-...w. ...,,...w..uuc....... �_.-_ <br />