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APPLICATIOwFOR PERMIT PAYMENT 'Z SAN JOAQUIN LOCAL 1*4LTN 01miur" RECEIVED sr . 1601 E. HAZELTON AVE.. STOCKTON. CA ;;h: i`A : E. Tso (M)a88-MI f�. � do lfipt. ttir PERMIT EXPIRES 1"VItAR FROM DATE WSUED ; 'EA ' _ II'VIRQNM NTAE EA, H (C;;; lets in Tfiwkitel PERAA!TISERVICES a � Apo orlisat Is ttareblr"nada to the San JoatWn Local Health Dint I=ftn a MM*TO W1`111IM119A WWCW IRSW&-a vratk hsnNr daseelbrry d.T1th ' nada �ance with San app in corrk i Joaquin County Ordirtancs No.$ll2 for>tetrtttpe of No.;tBll2 for wMllpump'..1 tlta Rubattd Rapufatilsta of tM San Loch"So"Dimict. Am T Jab Aiibllws ZQ.LG LowF 4,sac c La.SAN PfiA owrwrti Marna s1�2rLi_ �j-�r� CO. Addran :;�1 BUe. I�eD . .r_ PhaN " 11.1 Corlhacter �1" .�'�I �Q Redress :lt 9119 ffl 'oiLkais NGS;drz `ph a � 0 1 ' TYPE OF IMELtIPV1NP: NEW WELL ❑ WELL,.REPLACEMENTiEl., . DESTRUCTION fa tt : s F PUMP INSTALLATION 0 SYSTEMREPAtR D a OTMER$ Sol%- %06 T�� "3:. '� '§� ! DISTANCE TO NEAREAST': SEPTIC TANK SEWER LINES' "f` DISAL FLO. PROP.LINE k�� T FOUNDATION AGRICULTURE WELL " t OTHER WELL PITS/SUMPS „ I• f{ tNTENM USE TYPE OF WELL PROBLE MARE•A CONSTRUCTIONS []'btdt+ttriai: 0 Open flottorn N. 1�Manteca Da:of Wlep,Eat 4atlon ",, ., *Dia.Qf VUaM��.._ Y, a: spa ' f Ll Derhl stelPehrare L. Grovel Pack, ° r`1,Traty b+. L �Typeol C Ina: I'1 PubRe - f-1 Other T7 bells ' ! �r _ , ..:t'7 0!Oran .. Dtpth W tloul Sul ype 1 I b"gwior. -- Approx. Depth I I Eaatwn '"� Swim Sial A'211 no tT hepair Worn Done 13 Tvw. of Pump H.P. �I. State Welk Dor. ` ler. Wd Oetitructien 11 Well DWnetw SeaAip Material I"WI QR ' .h Depth Fran Malarial IBtibw'S0'1 TYPE'7F SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION'!1 fNo septic ayagrrt punwtted N public sawar is .' «� � aWlifabla iMitltllt 200 hsiJ � x � '` , MttMatirnl wA serve Residence_-__ CarnmercW Otter Number of lump unft: Numb&of bedrooms Character of am to a depth of 3 feet: Water tabM tftsptlt ' I� SEPTIC TANK f-1 Typel Mfg -- ---- -- - Cspoci�Y-.�_ F10 CW"P&""&ns PKG.TREATMENT PLT.1_l .. MWod of Disposal Distance to nearest: Wel Foundation_ ` Peopury Lina LEACHING LINE "I No.8 Length of lines f Total Wilithlalts41 FILTER BED 1 1 Distance to neereat: Well Foundation,�.�,_ PIOPwt LNta SEEPAGE PITS i I Depth --S440 a NunlbaT SUMPS I i Distance to neared: WellFoundalkm Progeny Line DISPOSAL PONDS 11 I►wrebtr Certify that I have prepared this application er+4 that the work will In done in accordance with San Joaquin Coto"adinirlMa,state sawn, ander"' rules and raprlatwna of the San Joaquin Local He+ith District. 1 Homs owner er IK"Md agent's Signature certifies the logo winO:"I certify that in the perkwmana of the wotti Ior vrftirh drier perfm is www.'10*1 not rugby any parson in sutih manner as to become subpet to wwkffw is com4*nsation laws of Cafifomia.-Cont►setor's hiring or sub-comradlflp swwtm ,. cardlim the following:"I certify that in the perfomranaa of rhe work for v*dch this permit is issued.1 shat employ pwom subject to workmen's eontpatttla 1i tion laws of California.- The appfican t cad for all requ' spaclions. Complete drawing on revers 8rda. sigrtad 7itla: a. Data: •V ` `. s + FOR DEPARTMENT USE ONLY= Aprificatien Accepted by` _ DSM s1=11K-(�C Ana A I , Pit a Grout Inspection by Data_ Klnal Inspaetion by _ Data `- Additional Comments !� •' f ' n ' L" Still 166.6781 Odi 3693621 0 Manteca 82371p4 L'Tiacy 83544 1 Apptw"t• Brat all cogs to: Emnronrrtentai Heatth Perrt►iV5etvic,! �}i E. Haeatton Ave.; .p.Bo=2�_.S1k/,,W 95201 INFO AMOUNT Duf AMOUNT REMM.Tto itifa YE ay CA" 1111111111101 r�..w .i .r J .