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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. T <br /> Telephone TON. CA <br /> hone (209) 456-678 <br /> PERMIT EXPIRES -YEAR FROM DATE ISSUED <br /> 1Carrpiete in Triplicate) <br /> Joaquin County Ordinance Na.548 For sewt+ge or No.11362 fol rve&pump and the Rules and Re(lulatiorts of the San Joaquin <br /> goplica[ion is hereby made to the San Joaquin Local Health District for a permit to construct andlor i•tstaH the work herein described.This apd,ca[,or,n <br /> made in compliance with San <br /> Local Health District- _ 5! M/,,'7cCk <br /> }C F City ..r lot Sire�-�--- PM <br /> Jab Address z -rh Nc 4tr z�i enn�f ro ..:�7—8YCU <br /> �! r� 134 A f rte <br /> (4411.11) <br /> owner's Nary{ Z>J&- N Phone <br /> t'7 JJ 5re rr� G� Litense No.�---- <br /> SC-S+E1v y/NcF_/e5 Address DESTRUCTION r <br /> Cantractor WELLREPLACEMENT i~ R MU/J17LlJhse w <br /> _ NEW WELL ❑ SYSTEyt3EPAIR ❑ <br /> TYPE OF WELLIPUMP: PROP. LINE �S <br /> PUMP INSTAL LA7ftp SEWER LINES _ DISPOSAL FLD Lr <br /> _ OTHER WELL PITS/SUMS PS <br /> pISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL rr <br /> f FOUNW TION —r� <br /> TYPE`G WELL_ pROBLEMA�Eq C iN5TRUCTION SPEGI It7N5 p� of Well Casing <br /> INTENDED <br /> t15E 0 Manteca Aa.of Well Excavai f VV Spiiati. <br /> n Industrial ❑Open 9onom Tyra of Casin Y ire^s' c (�* <br /> Gravel Pack ❑Tracy} Tvp@yf Grout <br /> DomesticlPrivnts Hanr+n'j ❑ Delta Depth of Grout Seal �Nd ll✓� <br /> ❑Public Other Surface Seal Intmllnd by------ <br /> ❑ Irrigation H.P. <br /> ��lpprox.Det//ri❑ Eastern Stata Work Dane <br /> �^�'—x�fp <br /> Repair Wofk Dans C Type of Pump Coaling Material{top 50'. <br /> r Well Destruction G Wei;Diameter <br /> INSTALLATION❑ <br /> Depth Frier Materia!IBelow 50'I _�--��' rmmetl if jwGlic sevrat <br /> available within 200 feet.) <br /> 1 TYPE OF SEP�fIC/WK' Nfi1M11 REPAIR/ADDITION❑ DESTRUCTION 13 INo septic system <br /> `` Commercial Other <br /> Installation ,q serve: Residence— <br /> Number of badrooms�— Water table depth <br /> Number of living <br /> un <br /> Na.Compartments <br /> Character of soil to a depth of 3 feat: Catacay— ----^� Method of Disposal <br /> SEPTIC TANK ❑ Type/Mfg <br /> Prope,:Y Line <br /> PKG.TREATMENT PLT, Foundation <br /> C21— <br /> Distance to nearest: Wel!� <br /> Total lengthlsizs <br /> LEACHING LINE ❑ No. 6 Length of lines Property Line <br /> 1 Foundation__— <br /> FILTER <br /> FITTER BED ❑ Distance to nearest: Well�—� <br /> Numt'er <br /> ❑ pSize Property Line <br /> Depth ��- <br /> SEEPAGE PITS Foundation— <br /> SUMPS ❑ Distance to nearest: Wi41 -- <br /> �� ordinances,state laws.and <br /> DISPOSAL PONDS ❑ j;cation and ti,a[the work 411 be done in accordance with San Joaquin county I shalt not <br /> I hereby certitY that I have preparod this app signature <br /> I certify that in the p9e.)rmance of the work for which this permit is <br /> rules and regulations of the San Joaquin Local Heath District. <br /> Home owner or licensed agent's signature cer[ilies ttso 1ollowtng•m hued.I shall employ persona subject to workman*5 cortsFe� <br /> employ any.person In such manner as to become sun a of hsowork fol which� Per^srt of Cald1 s a' Gontraetors hiring or subwntraetirsfi sr9 <br /> r <br /> certifies the following:"I certify that in the pe <br /> tion laws&California." tions.Complete drawing on/reverse side• <br /> The applicant must call poi all r sired inspac �'r Date: <br /> -� �^4- Title: r� r&E o C <br /> Signed U58 ONLY f <br /> Date —r� <br /> A <br /> Application A spied by Date <br /> 0 to �^ <br /> �—^Pinel inspection by <br /> PA or Grout In by <br /> ' ❑Tracy � <br /> Additional Comments: � t.odi 369-�21 ❑Maniocs 1373.7104 Stk. CA 9520' <br /> Slit- arvtc .. <br /> 1901 E. Hazelton Ave.,P O.Box 2009, <br /> Applicant•Return all copies ter: Environmental Health Pann - - PERM11'NO. <br /> OECE1VED BY DATE <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH dt l e7 Z7-17c, . <br /> tN'0 <br /> •tea EM 71:4 ipEVvaSi �+!/✓ s <br /> C <br /> gnaw" <br />