|
Telephone (209) 466.6781
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEn
<br /> �IComplete in Triplicate) _---
<br /> Apitil"lion is hereby"We to tfle San Joaquin LOCM Haslah District for a pwm,t to corwrlrla and/(r wl%wl It-ww1 herein demoibed TMs application)to
<br /> made wi compMNlCe with San Jrragton CMlnly Ordinance No to/9 lot aew f{b
<br /> age or No 12 for wsllrpm411up a111" agw
<br /> r N,Jua nd Heulrinpll
<br /> s O)the Sen Joen
<br /> Local tleallh Draloct `
<br /> Job Address �j1546- City /� Q�a
<br /> A r
<br /> PM
<br /> Owren'6 Nanw u/V -l«"b-- Addeo" B qc U 2 2 (7(o-� 3�p../ i•hnr,,, 3 3 5�—tYiC
<br /> ' /� am`
<br /> COnhdcltx � �1A a16ddreN _/Gf✓L`_'Kr (.'�.dL* , I., 7.(, --—Y Phone 71.5-_•7
<br /> TYPE OF WELLIPUMP NEW WELL N WELL REPLACtMFNT UfS1RI)C1k)N
<br /> PUMP INSTALLATION A--- SYSTEM REPAIR I OfHIN �
<br /> DISTANCE TO NEAREST SEPTIC TANK /yT SEWER LINES DISPOSAL flU PROP LINE �Q
<br /> FOUNDATION AGRICULTURE_WELL OTHER WELL PITS SUMPS
<br /> INTFNDEOUSE TYPE_OFWELL PROBLEMAREA CONST RUCTION SPECIFICATIONS
<br /> Indu►1nN _ L�)Open Bottom ll Manteca Ow Or Vies Eeuvation - f T IfU�r cal Wol Crnwlp ~
<br /> (kmeahcn Prryate Re Cave/Pack t)Tracy Type of Casri9 �O
<br /> v' w'G
<br /> o -�_-- � Slx:uhn rtwns
<br /> Prar4c 1 I Other 1'1 Delta M, F.M.Deplh of(Twat SNI 4. _..5� TYLK nl Grout �/C��
<br /> Intl Irrl A
<br /> NH Aplrui, Deq 1/EaMern Swlace Sew)In►IaWrd by
<br /> Repave Work Done I 1 T
<br /> A�(b4-N/' ------
<br /> Type of Pump
<br /> u .L H P. -.- 10. - _... _--. State Work U„ne
<br /> Welt Destruction i I Wea Dwmeior �T a� SeaMlq Malerwl Itop SO'l
<br /> Depth. 0 frier Material(Hek,w W 1
<br /> 1yPF Of. Sl Pflf,WORK NEW INb1A11ATi, -41 1 Hf PAIR'AD!)I fiUN (HSIRIICTION. IN,.s.•hn, ;,•,It•m Iw�nnrttrd d puLlr,aewm rs -„�
<br /> avuLrhk•wdlnn Al)Icet I
<br /> Instaaatrrn"Mservo Residence CorrrrrrcrM__ Other
<br /> Nunitrer of Irvrrg I la- .. Nu0,4-1 of bedrouttew
<br /> ChOtALler of -4 to a depth of 3 feet _- —- -.._ Wah•r trhb rfeVln _
<br /> SEPTIC TANK I I Type IMfg Calw,ity Nu CumprnrnrnK —
<br /> PKG TREATMENT Pli i 1 Meth,nf Of Divlr„nrt
<br /> —.'--—
<br /> Ontance to reerest: Wait follrwLatwn ._ Pr,>fw•nv I nw
<br /> I EACHING LINE I I No i Lwhgth of Lew701.1 Im,ltt. r••
<br /> It ER BED l 1 Ortanca t0 neanMt Wall _ FdlMation r;;;;,r,�Pr„t„rt, I �,• .�
<br /> _ _ r
<br /> SIEPAGE PIIS I I l)eplh . . Sue _ Nunrwar `�\1
<br /> SUMPS 1 1 ('►tante to nearest _ Wall Foundation d
<br /> DISPOSAL PONDS (I
<br /> I tereby certify that 1 have prepared this rplWcation and that Ow work wrl Le dura rn a.cunfrrlcc cath Srr. I,I 111111,.uuntl ur,Lnancrs. sialr taws, and
<br /> rulirt and regulairrls of the San Josqurl Local 1{ealth Deiiiixi er
<br /> Nome owner a'tensed a1MrM's ugnalwe oertrhes the following •'1 certify that rn Ute p clO,,nance of the aur►ho wr,. h Ilya perml rs rasued.I aha)n0l
<br /> anlplov any potion n such manner as to become auirfrcl to wor►man's cornpenkl
<br /> aahun laws of Caunw
<br /> va”C,rllractw s hwg or wb contractrhq a.pnawre
<br /> cOnstwa the foaowrh0 ”1 candy that in the perfoemerr:e of the work for which th,s permit,s mb.0d.1 atw0 enq,k,y Ir,r y,ns wbina lu wurkrtan'a cortlpe/hy
<br /> tion Laws of Calllwrua."'
<br /> 1 he apfrrc ant ,►t coo for as requr rlKrectrrla Cornuate, awing on reverse safe. y
<br /> Signed X ,
<br /> 1� - Title __ (�ffY/.•L(-- - Urin V
<br /> ����hh��////'//���) Cf PARTMENT USE ONLY u_
<br /> Application Accepter by 1 Aria
<br /> 12
<br /> Pit .
<br /> Pr or 60Inspection Dv -..'al'. _ Daq .Firttl inapecbon by G/� GG Orta
<br /> Additional Comnenis -- /-.- ---- --_---
<br /> Stk 466 67131 I 1 Lodi 368 3621 C]Manteca 8237104 1]Tracy 835 6386 �-
<br /> Applicant Return all copes to Environmental Health PerriWServices 1601 E Hacetion Ave., P O. Bos 2009, Slit , CA 96201
<br /> Fit AMOUNT DUk AMOUNT"11111"10 set NICEIVED 8y DAIL Y111M11 NO
<br /> --
<br /> INFO
<br /> IN 1724 limy , + // C �•h `1 _-- rte_ ') I�I ✓ — SL
<br />
|