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APPLICATION FOR PERMITSAN
<br /> 601JF:.�FaZEZ.TON AVFGUIN LOCALFIEATOCK' CAT RECEIVED
<br /> } 1'cfr.Fhnne 120`.11 4156.6781 NOV10 1989
<br /> PEFdMIT EXPIRES i YEAR FROM DATE'ISSUEDV--ENVIRONMENTAL
<br /> V 1
<br /> (CDmnle:e In Trip,u'atel p� r,F1 •� �y
<br /> — ENVIRONMENTAL HFALTi
<br /> #, not to Co,jl,,Ct aelFor+`151,111 the workrFY4 lNf�t�Ip�t1� V'Cl7LB1ir7n is
<br /> Application is I+C,rtW made to the Son Jougidn L Hca!H.;�Irh[hsu+r.r fnr a fd" 5
<br /> n made in cnrnphanco wilt+fine Juuq„in':+,trn ty 01,1'nanr:u W,l !Alj hu s`1wdDe or Na. IF3t:.far v wlllpurnp Gnd this Rules end itetrcr..:iuns O: '+e hi JOA[p{Ip
<br /> Loc:+l Health n:smc,.
<br /> �J_so -+� – ---- -_- Size — PM _
<br /> _� env_��.--
<br /> s Joh Address —
<br /> - � Owne+'s Name -
<br /> t. ✓✓✓ ' Phone F�feJ�
<br /> 7 / License
<br /> Contractor,- ^eJ�---_. -^-
<br /> WELL ft�PLacLMENT : l DESTRUCTION i-1
<br /> +, TYPE OF WELLIPUMP: NEW WELL iJ OTHER Ll
<br /> PUMP INSTALLATION I�---_ SYSTEM REPAIR i.':
<br /> SEWER LINF,S _ _ DISPOSAL FLO. PROP.LINE
<br /> + DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL_—�..-- PITSISUMPS _-
<br /> FOUNDATION ..- _...____-- AGRICULTURE WELL - _
<br /> USE Typ7_+JF W
<br /> - ELI. PROBI,F:M AREA CONSTRUCTION SPECIFICATIONS
<br /> ED
<br /> i .q INT17ND
<br /> _ WELL R AREA
<br /> -'-._. - .----�---- __ T
<br /> Well
<br /> If`
<br /> Industrial 1.3 Open Bottom f� Manteca. Ula.gl 4M1nll Exravnt+on�.---.__ Dia.c0}cnteons acing
<br /> 1`YOo+nesritfprivatn Cl Gravel Pack N Tract/ Type n!Casing- - _ ' TyQe or Grtwt_ � ---
<br /> + I'1 Public (1 Other , i"? Della
<br /> Depth o!Grout Seat _ —._t. --
<br /> � ''
<br /> Apl?rox. P+ Eastern Surface Saal ln6lallad by_�_,.----
<br /> `.�a+.�i "'P._�.—:�_..-...----^'_'_—. State Work none
<br /> z Repar!Work Done fy Type u!Pump
<br /> 1 `,af r ;;uafin Matenai flop b0'1 _ ---
<br /> in Well Deslruction h1 Weil Dianeter _t---- 9 -- I
<br /> s4M' .. - Depth _.��--»-- Filler Material{pelow!xT!
<br /> '�ht rmr[mff if obit,11-111.1 is _
<br /> TYPE OF SEPIIt;WURM: N£W INSTALLATION i I REPAI7l/ADDITION 13 ULSIRUCTION I I available rwthin200feel.1 p
<br /> c;� ria� tS. of{�' .statlation will serve: Residence GommrrcOthef
<br /> x O
<br /> Number at living units:�_ Nwober of hod,00ms -
<br /> ?.Water table dapth.,,�.�---,•-.- ^-
<br /> 4�„ � k A r• x- .. Character of soil to a depth of 3 last:_.-. --�--
<br /> Ca,achy No.Camoamants ?
<br /> - -
<br /> ; SEPTIC TAN% Cl Type/Mfg - -- - rtMethod of 011p+7sat �-
<br /> w yc -' PKG.TREATMENT PLT.t] property Line r
<br /> W I a tq a - Distance to nearest: Well-car._-- Foundation-, _
<br /> { L"1 No.&Length of linos Total fengthlsire
<br /> i i rt��.n.,;'�i - ,• !� L>:AC fll1C LINE Propesty Line
<br /> �v 0.1k j.,x{ _ [3 Distance to nearest:
<br /> Well FiiOnetation--_.--
<br /> 5� FILTER BED.
<br /> i i Numbet .._..._ 'i
<br /> r�,r Ptnperty Line
<br /> '` d�33`ma�y 16�'{}i3Y' SEEPP.GE BITS --.Founda7iun�. -
<br /> .;SUPRPS ' "" LI ..ow.an:e to nearosc. '-
<br /> sr��, 4�46tayr � DISPOSAL PONDS
<br /> co:tity lhat 1 gave prepared this application and that the work will ha done in accordance.111th San Joaquin calmly.orQir7ancea,stale Laws and
<br /> 7; + rules.and rf_+gULatioru of the San Joaquin LocaE Iieal:r+03triet. ^ r
<br /> +.+” $
<br /> -,..,Herne owner or licensed agent's signature certifies the lotiowing:"I aonifv that in the performance of the work fpr which this peub- is issued,I dull urs
<br /> ertiplr7y my parson in such manner as to become submet to workn7an's compensation laws of Cal'rforr4."Contrac.oeb hying a sub.crx,trectin¢signature u,
<br /> •i r ,� �'-F t ,'certifies the lntlovrir•.g:"I certify that in
<br /> the perlormanca of the work for which this pertnit is issued,1 shall emp!Oy petrtom subiect to workman's compensa�:••-
<br /> ft r
<br /> d"Y`f" :wyx 'tion laws of CaGia,7ia f
<br /> � �t 7y .YF'l ,�• The applicant 1`117 t:b fnr all rage ad mspeCtio/ns. Complete ldrawing on reverse side.
<br /> 5 r flza/ L�stt - Date.
<br /> EIIREN USE ONLY
<br /> p �'' PART
<br /> Arun
<br /> �Ry .; •.' ... w_�� Date_
<br /> 'xy fe r q 'Appiicetion Accepted by �s•. �'� 'z 1'„ .
<br /> Final Inspection Date t
<br /> Pit or Grout Inspi,ctlerr by Date
<br /> 4 l
<br /> Additional Comn.rnts:
<br /> r7'Stk aFjs-6781 ❑LodIt 7S3-3fi21 ❑Manteca 823.7104 ❑7raty 835.8x85 -
<br /> �'
<br /> Applicant-Return all copies to: Environmental Health Perritl5arvicns 1607 E. Hazelton Ave., P.O.Bot,2�9.5tk„CA 95?Ol`,
<br /> RECEIVED aY HATE PERrJrT NO.
<br /> tNFO AMOUNT DUE AMOUNT REMITTED CASH
<br /> 1gvp r yJ �f �p - M
<br /> .t; '2r .•t • O 1 XtH
<br /> I. d
<br /> Td est 74-26
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<br /> A��' '�,•k��J'�;Y''�i.0 Epp.; "' +�tF
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