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*Mot Orr T I ,',,
<br />• li4tl4 iUfV
<br />P414 $
<br />I
<br />ii.fr.-.,..ir.erikritteo
<br />1 1 i • .?
<br />gAsu mtcrpvf n ay
<br />trry
<br />'
<br />INTENDED USE
<br />( I Industrial
<br />I Domestic! Private
<br />I"! Public
<br />I I lordatron
<br />Repair Wotk Done
<br />Well Destrirction
<br />•
<br />TYPF OF I.'/FI I
<br />Open Flottr,m
<br />RI Gravel P„,
<br />Om"?
<br />Appro. o,•011,
<br />Typ. of Piwir
<br />I 1
<br />
<br />Well Dtani..o,.
<br />Depth _
<br />NEW INS! AI I A NON TYPE OF SEPTIC WORK
<br />P.PPLICATION FOR PERMIT
<br />sAri • lAQUIN LOCAL HEALTH nisi mci
<br />HAZELTON AVE., STOCK 1.1 N
<br />TnInnhone (209) 46667W'
<br />r ETIMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />(Complete in Triplicatro
<br />aoribcation herehv made In the Co. J0,1 ," 1i H e ,erh 0,11,4:1 ter e permit to boom', • ..or he
<br />made in ,ornotranre won Se. roam., ,• tin for erlwaree 0111041962 I" • • t• 1,4 , and th0 Rules a-;.I II.. '
<br />Local Health mimic! ,
<br />Thu e aortic:term, is
<br />the S n Joareen
<br />PM
<br />-.1.17-2 ;5
<br />Job Address 4648.. Eas Wa Road
<br /> ' •tify ,4 1 t 7 1 Of _
<br />Owner's Nart111 t.irIciwc r P ...!r L
<br /> a.i•oets, _BOY-11 1
<br />4_10 .Eudza_Rd....P.ittsbur.:L !,.alIBU:
<br />WELL FIER Amirrtt Tmlf:TICIN
<br />SYSTEM REPAIR OTHER
<br />SEWER LINES ,•5(1)._:__ DISPOSal FLD _N/A_ Prior 1,3q2_
<br />AGPtcuLTURE WEI rILA. (in-KR wE1.L :vet._ PITS ';uml
<br />'A
<br />CONSTRI ,Crint: SPFCIFicAtiONS
<br />Dia. of E.( iyaron ____ _ D.a of Welt Casing 2 1' —
<br />Type u isino ,pvc: Soecoications .020
<br />Depth of Grout Seat 25 Type of Grow( omeitt_n3en to
<br />Siorlaur Seal Iner0.0 fly _pi t um_ F..),s_rtj ra t ion
<br />H P State Work Done _
<br />Seal! iq Material hop 911
<br />Filler Material 16e10w 501 . _ ________ _
<br />if A111 A I 11)111011 I • DES 1 RI IC T tON No septic system permitted .1 noble: sewer rs
<br />available within 200 fret
<br />Prt()FILEM AREA
<br />Manteca
<br />Tracy
<br />Delta
<br />LiNforn
<br />Installelton will serve' Resolence Commertoal Other
<br />Number of living units• No•nher of hofirnrune
<br />Character of sod to a depth of 3 te.,t
<br />SEPTIC TANK I I Type Min Capacity. ..___
<br />PKG TREATMENT PIT I 1
<br />Ofcrance. to no•mr.V Welt
<br />41 fln I error?, ot I
<br />• --."' • .,,
<br />I I Distance to nearest Well ____ °Wichita:Mt — _ Property Une
<br />_ —
<br />SEEPAGE PITS
<br />SUMPS
<br />DISPOSAL PONDS
<br />
<br />I I
<br />I 1
<br />I I Depth Size
<br />Dstance to nearest Well
<br />_ __,j; .ii , I
<br />4 _ unu ,....
<br />, i
<br />t i.
<br />oation _
<br /> Nionber
<br />. _1 Property tine _
<br />I hereby certify that I have Prepared this apple' anon and that the nrodtAtillate In accordance atei ttt1::!an Joaquin county orttri••••celii a
<br />rulers and regulations of the Sari .1.1.irium Loral ff..afth GoltreTt .'4-1,-,
<br />Home owner or licensed agent's signature I °tribes the t011owing: -1 csfliMth.$ In the performance Of the work for which this peon.t rt.
<br />employ any person in such memory as to bnr nine ..1 'Newt to worlimeni . . Pon law, of Citilf0110111.' COglIfiliCtOrS hiring or soh r oriole
<br />certifies the following: "I certify that in the ryirformance of the work foe. this permit is issued, I shall S.rnpkity persons subject In w °dirket),
<br />tion laws of California.- IT 1 '
<br />.,,!•,. . . N.,.
<br />The applicant must cos lot as 'mooedw
<br />
<br />rrrorteins C.on.plofer drawing 011 reverse side. ' . . . ' ' i‘i'' ' A
<br />...f.' •- ‘ Signiftl X ,,_ . Title. . -
<br /> ' r.' ,171 e. ..e..-...i. Di • I ,
<br />' / 1 ./'''• FOR DEPARTMENT USE ONLY
<br />. . • .
<br />! ,
<br />
<br />_ , . '',r1-(141,•Y' I.
<br />L, ;:.„,•-+
<br />Application Accepted fly 1_, _ ___ ___ r. Date .1i
<br />14 I
<br />Are.
<br />Pe or(Grout Inspection by 01..i.e l. "..)"...,...D.ii'e --7 -; V.:,Fin'el'Inspecynn by • 6, -▪ . // 6 w-1-1.1.. ' 0•16 .---•1. ./ ;* , ..,
<br />-
<br />CI Ste 456 6781
<br />Applicant Return all copses tn tnrroiriufiii it,. tott Permit/Serviette 1601 E. Hiselteis At., P 0. dos 2000: Sit., CA 95.201
<br />Additional Comments _
<br />IMr "tn't TIC:1 Menteca R23 7104 C Etocy% 111C 6385 •t;I
<br />1
<br />LEACHING LINE
<br />FILTER BED
<br />Foundation
<br />Water table depth
<br />No. Compartment,
<br />Method of Disposal
<br />Property Line
<br />t.itot -
<br />
<br />Contractor -4)44-Eime. 1-11
<br />
<br />TYPE OF WELL ;PUMP 'If '.'„ V.1 I . .
<br />PUMP INST ALLA lION
<br />DISTANCE TO NEAREST . SEPTIC TANX
<br />
<br />COUND A tint! '
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