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APhLIC1TIbN0'�3'pERMIT <br /> aa SAN J4AL2UIN L4CA1.ri ► .TH.ISIST.RICT ` <br /> IC�'DN- GA <br /> Tatepf�s`{ } +67� r <br /> PERMIT g PIIitS ( A t R�1�1 RATE ISSILAD <br /> 33 <br /> Y �.A s *. :cam ■1{w <br /> M <br /> \ ONY p <br /> Application lif hereby' tb,tha San;Joa4trin�or:at'#irraMs l fr¢t� t t" fid/�44 ir}s lll�ll riorlcherf +le3txib d 1"ktis apgl}catKtr+is r <br /> made In corn Bance San:.Ioequiq trourity 7j etYnCti filo,549 of " IAR ander tyles�lrKl� dlatiorts Of the 5anoaquin <br /> Local Health Distric <br /> fr y ^t k 'ver a" t <br /> ttl42 <br /> Jr" r t Fk *, 'x a4 �ltirr v+1 Laf Stze t`x'`x <br /> Job:Address PM <br /> Owner's Name �FA�LG�u 'Q.� t_ons "_.: Address .. � W,�ci� Sl�r�� Phone <br /> )49L <br /> TYPEContractor a Address':' 3d ^.a¢irori:.aPe"F. aiaRa.- License Na.�Yg a'8o+► f'hon <br /> TYPE OF WELL/PUMP: NEW WELL U90!3-.,; WEL,REPLACEMENT 0 'DESTRUCTION 0 <br /> PUMP INSTALLATION 0 'SYSTEM REPAIR CI' OTHER 1 eee! <br /> DISTANCE TO NEAREST:'SEPTIC TANK &A SEINER(LINES f L f/. R .. <br /> �(c..,� DISPOSAL FLD.�_.PROP. LINE yf's '` <br /> FOUNDATION . k//.r AGRICULTURE WELL,/- OTHER WELL J✓�"PITSfSUMPS <br /> INTENDED USE TYPE OF WELL L. PROBLEM ARFA CONSTRUCTI0ff SPECIFICATIONS <br /> ❑ industrial ❑Open Bottom © Manteca Dia of WellExcavation Dia. of Well Casing <br /> a 6. omesiic/Private' ©.Gravel Pack,, © Tfacy "" „;YPQt>f Sjtt�`AVr Specificatrona. <br /> (`I Public ; Vio'AC vgnn(7 Other 1"1 Delta Depth ps iCinwt Seal ' �P Type of Grout Alrr4 .-CA;^t <br /> I I Irrigation REuwC?d & Approx. Depth i I f astern Surfacii Seat lnstallad by 1i t f a• <br /> -Repair Work Done ❑- ' Type of Pump` H,P. - "°° State Work Done <br /> Well•Destruction ❑ :Well Diameter Seal rtq <br /> Depth Fillei'Mai "60'1 <br /> r <br /> ''TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITtON f 1 DESTRUCTION I I INo septic systemrmitted;if public sewer is <br /> PB «a <br /> available within 20U festa ' <br /> Installation will some Residence'_ Commercial'_ 'Other' �" �`�' ' ;�� ,a t2 <br /> Number of living units *lumber-of bedrooms y <br /> Character of soil to d depth,of 3 feet: _' W depth <br /> 'SEPTIC TANK ❑:,Type/Mf r. f <br /> 9 .- Capacity No: Cornpartmertts <br /> r, <br /> PKG.,TREATMENT PLT p, Method'af Disposal <br /> ,; <br /> Distance to nearest: Wetl' Property Line � � r <br /> LEACHING LINE ❑ Na. & Length of ' To thlsi:a <br /> FILTER BED ID Dista nearest: Well Foundation ^ Propeftr4j e <br /> SEEPAGE PITA..,r' ' I I. .Depth $Ize ` t '` .Number <br /> SUMPS- Ll' Distance to nearest & Weit` " Fouirdatron Property Line <br /> DISPOSAL PONDS p <br /> I hereby certify that I have prepared this application and that the work Will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Driltrict. '. <br /> Home owner or licensed agent's signature certifies the following-;..'I caddy that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X fi _.E . ) � Tithe:-!' .;_ , r�/. Date: <br /> FOR DEPI�1�1`f y���ONLY <br /> Application Accepted by f)aa `• Area" <br /> Pit or.Graut Inat n by Date Final Inspection by Date . <br /> Additional Co, <br /> ❑Stir 466-6781 " ❑ Lodi 369-3621 ❑ Manteca $23.81(34 0 Trate <br /> Applicant- Rtrtum all copies to. Environmental Health Permit/Stirvitlbs,1�" liatatltoii Ave' P O Box 2009, Stk, CA 9fs"201 2 <br /> FEE AMOUNT DUE AMOUNT REM17I EDI <br /> r; �IECENED;tiY DATE � ;�RMI7'NO r �g ;� <br /> INFOwss�� �. <br /> EH was ��� ,�._.: :, sr��••�� � �'s; ur.jr M�.' - <br /> - r ,r <br />