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4 S 17 <br /> 'PIephone 1''11,•4`-1-6''1 DATE IaSUED 7(� <br /> ;•,it•;; E.I•; 1 PES YEAR FAMI. N.•E ISSUED i <br /> iromplete in Triplicate) <br /> Application is herety -ade to "° %+^ "tvutn local Healin <br /> th District ��unt PD dinanceernit to cNo. S49 forsewage <br /> NO-h1862 for well/pump <br /> S49 I � <br /> deSC N Ded. This app:iCatin•• ^"•' i'^lidnce with San Joaquin Y <br /> and the Rules rd �egulat:o -%:,u'n Local Health Diste':t. <br /> (_ Subt'Iv�slon Nam! <br /> Job Address ac Dnont <br /> -•� C(idd re s s <br /> Owner's ham! �_V_�_1�v-. ���L��-\ � �• Doone <br /> C6ntractor'S Name LE.E.__wt�`Z"`��'`•••"3'ense No. CIL <br /> i WELL REPLACEriNT I`i DESTRUCTION L1 W <br /> TYPE OF WELL/PUMP WORM.: J OTHER i <br /> P:OP :'.•7AL.:7:^Y (i SYSTEM REPAIR 1-1 E._�DISPOSAL PLD.SEWER IiNCS PROP. LiNE <br /> riSTANCE TO NEAREST: SEPTIC TA'.r -- <br /> AGRICULTURE WELD DSHED .cel rtrSlSlt'rS �� <br /> _ <br /> — pa10LCM ARF0. CONIIRUCTI^N SPS EAT1OK <br /> INTENDED USE ._`- -.- --- Dia, of Well Excavation — <br /> 1 Manteca <br /> J industrial ;Iia• of Well Casing <br /> Dprt,eStic/Privet• <br /> r'.rav•: .�,• Trac' <br /> LJ _ •---- <br /> Public l.: t_J Delta 1yp0 of Casing <br /> .. , Eastern Specilitations _-- <br /> irrigation - _.._ <br /> :'+•{:h Pp <br /> Dti. o/ Grout Seal <br /> n Cathodic Protection �i <br /> ElGeophysical <br /> Supe or Grout <br /> l�Other Surface Sr+i Installed by - <br /> r1 H.P. _ T State Work Done - �- <br /> Repair Work Done u Type or '"' t' --- <br /> Well Destruction 1...) Well Diaretlr Sealing Material (top SO') �_-• <br /> Depth --•_-_ f{11Pr Material (RPlnr 50') r.___------- r <br /> -- - alef,lR/ADOItIOV I (tu septic tank or seepage pit permitted it public sewer is <br /> TYPE DF SLDTIC :I:`RA: hFW 1':ST�:.�': • <br /> 1 available within 200 feet.) <br /> Com+Prtial 0thnr <br /> installation will serve: F ti -- ,- _ c 1 r <br /> --i '..,-.�r nl bedrooms —Lot site <br /> Number of living units: 1 s Water table depth �-- <br /> Character of soil to a depth c•' i ^'' _- N&7U No. Compartments -- i <br /> �0�� Capacity _ Q�Z r <br /> SFPTiC TANi 1ppF" -�-k Method of Disoose) i_- — > <br /> __ C+Dacity _ i- <br /> P,G. TRLAtMLUI rL1. L_J 1vr••'�"t --_ i�Fou*dation ~_ Property Line - <br /> SEWAGE SYSTL" <br /> DESTRnCTIn'. V _._.- ._..... ------ --- --•"---" `Petal lrnotn/sltP _+T � --' <br /> - - •in, lines prOMrty line -_. -- <br /> L[ACHING Ll`.E t- .ell �o A7 <br /> rILlER RED -N�-Mr- <br /> - <br /> prline <br /> SLErAGl j'I S t: n•11 __-. rqundation npPrty <br /> SLa,rc <br /> JISDU�aI r;ti?ti <br /> nertby <br /> cert •iat l "'•' atpticat•nn and that the nwry ri11 be <br /> eh ole in accordance with 'an Joaquin county <br /> 1 ii;•onS o t Sin Joaqu local <br /> ^ , ` n•a r Loaf in the performance o/ the work for which th <br /> ilL <br /> Ordinances, Stite IJwS, J. '�� '1' •.rtlr{PS t^C r011Owtnq: 'I certify <br /> ^,v-e Owner or 1•Ct•^•.•-J d;'.r•-'-. h nnPr aS t0 ,0co-' tubSKt t0 wOrkrNnS COmDenSatiOn laws a C+l.rernihic <br /> ;,.r•,rn in aut ma m•`"r.: " certify that in the percOY*'ance OI the work nor which <br /> �PY-il IS 1SSJP.•., a,•i, .. •.it Ure C'•rtifios t1-P O.i <br /> ^FPsation Lars o1 California." <br /> . .,;to s i,ir+.,I ,r •.. .. - .. tu:,lrtt to rnrs^an•s cn-. <br /> • • r-•t .q ••� " {n O. reverse d!. <br /> ;.•Clinna, io"pI PLP iw _ Date: —7-'__4 <br /> Ck ,E�;cT"'.'.• USE rNly Sts 466-6791 <br /> Gr•a <br /> Loot 369-1621 <br /> t:':- 7T'1 r',A+a..►�4f1Y_+� -- �- [� <br /> )O R21-7104 <br /> TraCY R75-63ES <br /> Nato 31.f-v + L.n. a,. 2009, '.s C' 95�G1 <br /> i'•. - Pri••Sr.�i.P: lY•Oi [. •archon "v•• <br /> ^_mal .•rai• . _ <br /> ,,- - - .. - .. ----- -•-1----='�-�°E..E--I^'pr' ' ♦E _�_ •moi-~��,^--- <br /> EXHIBIT C 1 of 2 <br />