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a <br /> ,-Ev .,IMR, <br /> x <br /> APPLICATION FOR PERMIT <br /> SAN,lOAL1llIN LOCA•HEALTH D1STi�ICT <br /> 1501 E. HAZELTON AVE., STOCKTON, GA <br /> Tolephone (2081 46 <br /> 1 <br /> . YEa1R FROM DATE ISSUED <br /> PERMIT EXPIRfcS plot,in TAPlicate) <br /> Thea avPl�'"n a< <br /> (Comp ;rrstast the work t+srel^ u ,of the San Jos4uln <br /> 4istrict for a pentane to t9a CI for^rl�p'mp and the Fluff�Rr0 <br /> made to the San Jpequin Local Health sewe4e of No, <br /> 4 will Sen Joaquin County Ordinend N°. PM <br /> Application s3 tlerehY <br /> made incomPl`anc0 a Manteca Lot Size�`~ <br /> Local Heelrn R1str>ct• 415)357-8400 <br /> 229 Moffat Street 1111 139th AVS• San Leandro Photo <br /> Job Address Address. 283326 Pnonel916)662-282 <br /> Golden Grains <br /> pvrner's Name East St. Woodlandtic�e N8•�--� <br /> Core•A4dress220 N. DESTFIUCTiON ❑ <br /> ism Water Develop. WELL 11 LACVAENT O DTHFR 91 G.W. Mon <br /> itorinJ3 <br /> Ccnlfactor NE1y WEIL SYSTEM REPAP't ❑ PROP.LINE <br /> TYPE OF wEI,LIPIII P: DISPOSAL FLD�.�' r� plTS1SUMPS <br /> PUMP INSTALLATION Q SEWER LINES �OT <br /> WELL,,�� <br /> EA,EST: SEPTIC TANK r,��' AGR1Ct1LTURE WEV- T10N5 'r <br /> DISTANCE TO N POONDATtON�� �NSTpUCTION SPECIFICA rr 0y,of Wea Casing ed <br /> Ir— <br /> TYPE OF WELL PROBE D;z.of Wed Fx apQRSCH 40 CS SPS' ipO� Bement <br /> INTEND ❑Open �^etBonBo QEMW� Type of 12 A rax 25' Type��rp°rra <br /> ❑Industrial a GlAve6 Pack TtacY Deptft of Grout Seri —� ter DevelO <br /> Soo <br /> ❑DomestielPrn+ate (X 01tw sand D Dale _� Suri Sed 1r isd <br /> by❑Public State Work Da+e <br /> r�() Vvr=•�h— 6 EastsrtrH.P. <br /> ��— Seakrr9 Material 1toP"tri <br /> --��ttri�1Ort [� Type of pump ---�'� perrtlstted H w4lic sower is <br /> Repair Work 0°" 0 Well Diametar 1� FHW Material l8'el°N'5D 1 US;RON a MO"Vac M foe-1wait❑estival°n Depth r--�~ DESTfI ave lahla w thin 2W1.) INSTALLATION Q REPAIRlADDkt1ON 0TYPE OF SEPTIC WORK N a Qttter�� <br /> Water table daPth <br /> lrutallatien well verve• R° Number o�f bedr°°"t'--- No Compartments <br /> Number of living unity: pr.3diy_---' of Disposal <br /> teat: Method <br /> Charact°r of snit to s n�T�lMfg <br /> property Line�--r <br /> i SEPTIC TANKT �� <br /> 7REAtifENT PLT.❑ Detente to nearest: v+alt Foundation <br /> PKC. Total te+tgehlsexe <br /> property Lina <br /> Length of lines Fpvndation C" <br /> ❑ No.!A Lang Well�r <br /> LEACHING LINE ❑ Distance to neap' <br /> Number <br /> sireProperty dna <br /> FILTER BED s <br /> ❑ Depth 'r`f�Well��-� FlInd"llon�—� abate taws,ails <br /> rant: n. <br /> SEEPAGE PITS ❑ Distance to nee San Joaquin county ordina <br /> rdan-with i 0-1 no <br /> SUMPS ❑ rk will be done in acctrr <br /> 415POSAL PONDS lication and that the wo o�anca of d"work for which this pamnt <br /> rad this 0 C°nuectofs hiring or sub wn9actn9 <br /> I 'a ns that l have PRS uin LocAI Health Distort. „t certify that in tt-I ldom'ss• workman a cart Perms' <br /> I 1 hereby an Joaquin Ka Ilia taitowins. tion laws.of Ca ll employ Pers°r,a aubiect to wo <br /> rules and fagulations at the nt'a isgrtature cel subject to workmen s comP� �ensued,l she <br /> i work for which this tMr <br /> Home <br /> owner w li n'ln SA nenner as to bac domtanca of tt+e <br /> employ any ° 1 cartifY that in the im .ode <br /> certifiesttie following:" to draweng an i8"° Date: <br /> tion laws of Caldomia:' uired inspaelons•CamPle <br /> The aPPIiCBnt must call for all req Tom: r <br /> f-0R DEPARTMENT USE ONLY Area-------- <br /> signed J lr /' pate Dffw <br /> / faf[\/�,CLii I by <br /> APPliC3tion ACcePted by —� Onto�� <br /> P1t or Grout Ins PeCtOn try <br /> B13.7104 ❑Tracy 0,Box:AOS•Stk..CA <br /> menu: O Lodi 369' 1 ❑M peormisoviae 1801 E.Hazett°r1 Ave..P <br /> 3 StionalM 678' Terstal Heed <br /> ❑Stk t°:Emrison GATE pEfrMIY <br /> APPIic'•nt'Return all coPiea RECErYED By <br /> FEE AMOUNT DUE <br /> OUN7 REMITTED ASK <br /> INFO <br /> EH 4121 IRfY.��e 7� <br /> tH 1r28 <br />