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<br /> �� •APPLICATION FOi�,PERhA�IT
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<br /> Tr y SAN ,f OA U N LOCA 1'IE�ILTHEDISTRICT
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<br /> ` 1601 k E I f'E'�T,ON AVE., qj0�N�CA
<br /> .;�' TBI�E1pTlOne IZOJ} � 7 ,
<br /> r 1rg, PERMITE:CPIRES 1fF�►R�FROM D ISSUED
<br /> .Y {,. „� {Cornplebe if1 Triplicate}.
<br /> Application s hereby made to'the San Joaquin Leeal""I I District for a pemik 10 construct end/or inataM,tl»wwlt herein �. - r
<br /> made hi c6rnoo6be whh-Sen'Jopuln County Ordinance No 519 for'tewage or No 1BB2 for I/pump uid the RuMs`arid Ripxlatbtts a Jt
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<br /> Local'HeiahFi>Disttict.'
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<br /> y� Job Address ' tltsSitta
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<br /> '� _ �a 'y;'w 3'T�.,�j � t.� � �� � �/ iN! � - `�PltorM � �r,�a. ° �r,•
<br /> Dvvner r Nama Address
<br /> ���� � �Addras:°.= G a � l:ceilse;Na. ' °'�` ' 'f'hMle .• �
<br /> Contrac a,
<br /> TYPE OF.WELLIPUMP: WELL 1�' 'T WELL:REPIACEMENT'Cl DESTRUCTION �r
<br /> b PUMP INSTALLATION 1 5YSTEM#AEPAIR ❑ OTHER f3
<br /> r "SEWER`LINES DISPOSA FLD. PROP NEI
<br /> DISTALICE,tTO:NEAREST:.SEPTiC7ANK �' a " a*
<br /> F011NDATlON' ` "GRiCULTURExWEL - OTF�EFi WELL ` PITSIStI#il
<br /> NTE DED_.USE j ° cTYPE OF'WELL PROBLE4AREi4• COkSTRIICfION SPECIFICATIONS .ile
<br /> y4 Clnd l¢ Gly pen Bonom. C7 Manteca Dia'of Well
<br /> Excavationes "_�' Dia ot. eE.Caa'nE
<br /> n • 3 ' d r: tczo Gat
<br /> w a¢eeitica Ia
<br /> D0Ma5191 ate d 0 Gravel Pack f]�Tracy' �, Type%A��9 R
<br /> �` ❑ Pub th of Grout Seals TypeGrout
<br /> ❑-Otfier `l'( ❑ Delta D .dl,p•r, "e:rr.�r�s, v td`s'z,e
<br /> ,Yrw � r r,.,4 c M t.
<br /> 1Gyetion I p pprox:Oepth,�-❑ 1Eastem� SurtaceSaallnstafledby
<br /> ' g .*n;P o 7 r°` ` ' r"c.� �'.'�'���,+�� Stala'WOTk{Done'
<br /> R�f•� ON Done C] Type o}Pump w r x� ,�:,r �
<br /> 50'
<br /> 114�e11 best- ct an: ❑ Welt Diametar� ,t,rr9„tom�,� ,��,,,y„ ���Y p,�w� pyo - -
<br /> Depth�'��`f '` ' 'r�'t r� Fdkr.Moterial IB c '1
<br /> mdtted if pttbYe'aawer..k
<br /> r r T,YPEyOF SEPTIC WORK NEW INSTALLATION❑ 'REPA1 rADDITIONr DESTRUCTION�a evailahpp within 2W feat M
<br /> 5.3� �* Alii A �Y Sh�l�� f�N U� �n �•'� ' J )P� ,had. � - S Va^� � _
<br /> pe II
<br /> � natal'at n'will serve Rt sldence�^��i Commercial �”Other `' t i ",� �-�xr�� yWkW��i'
<br /> f Y wl a 1g 4 5 ,
<br /> i »eta 4 �. ` t ,-� > * l• ` i« c
<br /> y Water table depth.^
<br /> !Number of Iiv�ng,un�ta kMumber of bedrooms y l N t l ! r rn
<br /> Chs�y it ti �� iX ; F
<br /> raC or ofiaoil:to a depth of Veal a „. Na Ctlmpartmentst
<br /> ,dn:�krkw.. r r - t F.. - c+ +-Q? BUty'`i°_ ° `- �n�,
<br /> SEPTIC TAN ❑ 7ypelMip ire p W i
<br /> fi i #`'S�{ i k�5 � Method o!Dtsposel,
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<br /> +�"� ��+WeR I? /i rfi, �Fouridation# �� , Property tw.tne
<br /> �. Distante�to reareat
<br /> A � t• Y �l ,,-'�''F t, ,i !r. ;rev s�A e53ss"�.+�Iv�h �fa� a:f3 '�..s�'�
<br /> .•t+LEACH;NG LI dw �t'C]: No'�8 Length of lines� s ,,, 9 ly���k��x a �fi
<br /> L'7`� Drstante to nearest y Well �' Fauridauon�.-�,,
<br /> k fi Size° ' c 3 NuM,
<br /> SU GE PIT "_ 1. Depth n,,w
<br /> s , xt:�vA Pro rty Ltne
<br /> ❑ 14
<br /> {Distance to negg�rest tWell� a Foundation
<br /> DISPOSAL PONDS ❑ �� ` . 11 afit
<br /> thereby°Bartl4.that t have,prepared,this'epplieatlon;and,that the work wrll.be done in occordante.With:San,.loaquln county oidinancK
<br /> .M .: 4
<br /> rulea'and'rapuiatloni of the;Sen JoaQuin Lotal';HealtTi"District
<br /> H074:bwner,Orellcensed a0ent's.sipnatur oinesub9ettto wdrkrnan'smcomtPenaatien lawsoof Cal omieh; Coritrector'.aihlrng o�w c"or�trattinpFiintia 't
<br /> -s•�'-' employiany person in sUch'ri+anner es to
<br /> tcartifiet the following I certify That in the performance of the work for which thle permit is issued,'I ahsli amploy,Person��ub�et.to workmtn s e
<br /> r, tloin'Isws•of Californiaj, �"� r ; �' stds. ,
<br /> 3 I, a equrre Uorn Comptefrrawing
<br /> t1 f.aw,ra�r �%
<br /> The app cant m at c or.
<br /> a a � j #� Tl yr * h kQeta:, A
<br /> DEPARTMENT USE ON
<br /> 1919-7Date. s
<br /> ApPlication Accepted by , a l�#'�r
<br /> 4� 8 , �, >r Q 'f! �Final Inspattion by
<br /> E ax
<br /> pit Grout Inspection vy gya�i::
<br /> l Date .
<br /> r r w.- c7iw17+7. t"v5<G '.w t 1 ri,w
<br /> a a��ti;�
<br /> }E t'Add,tlonil Comments a� * ti'{G]Tracy
<br /> a�Stk 4G&5781��O Lodi a 3893621 . ,0 Manteca��t37i 7104 ,1 � t o�
<br /> Applicant"Return s11!spies to Erivlro+menta Heillh Parmit/Setvices 1801E Hazelton Ave.T O Box 2049 Stk CA 96201
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<br /> W A$ 6 -:: I r"G
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<br /> `RECEIVED qy Ey! DATt?w`, 5; }bERM1T iN0' !
<br /> IF EyAMOUN7 OU r F-AMOUNT REMITTED- !rASHo -
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