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-APkI6ATjON�1=fJ PERMIT k r
<br /> t:�',: �°� �.ti •..,:.-'•S , .,:>Y„.� .>: .- 'aF.:�d�+ .. ,.
<br /> SAN JOAQU114'16' H LTH,DISTRICT
<br /> .1601E HAZEL'fON4VE:, STUKTON, CA
<br /> I Telephone f 2Q91 1 r
<br /> PERMIT EXPIRES 1 YEAR:FROM DATE-ISSUED � �a .y } P '�•
<br /> r: 6i r,a 1• +�i �9ti t
<br /> Wompfefe itl fir pllcatta ` T
<br /> Y ('. d
<br /> perrdt to constrw and/or I.Install tate work herein described.This a
<br /> AppNoatioln _Ileleby tq thR Sen Joadten„l,044l Hgaltlt Olstriot fors 0000���� PP anon a
<br /> matte'�n.cbrribfthce�wi $atii lgaquin County Urdlnartc �IVq sy54S:tor aawage or N ifIQ for,wall/qumP and It Rules a1.
<br /> nd Fieguiatior�a of the anJoaquin
<br /> Local Health Dlstnot. g
<br /> ... .
<br /> Job AddressCity 'Lot Sia PM
<br /> Own4rtl1tr4fe �+^i n Phone I
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<br /> ContrBCtor' ' rb$IF"` 'S I�` 'License No. J�'/�?�ilPhone
<br /> TYPE OF,WELL/PUMP::.,.:x,:,;-�.;.. NEW.WELL_O.., WELL.REPLACEMENT ❑ DESTRUCTION ❑
<br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE
<br /> „,..,,...„FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS
<br /> INTENDED USE
<br /> `" `r`TYPE OF WELL PROBLEM AREA CONSTR CTION SPECIFICATIONS'
<br /> ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of W II Excavation Dia. of Well Casing
<br /> ❑ Domestic/Private Pack ❑ Tracy Type of C sing. k Specit'ications
<br /> f 1 Pu6fic ' f I Delta Depth of rout Seal Type o1 Grout
<br /> l I IrrigatI-,. Approx. Depth I 1 Eastern Surface S i Installed by
<br /> Repan Work Done ❑ Type of Pump H.P. State Work Done-_
<br /> Well Destruction ❑ Well Diameter Seating Material It 601
<br /> a r” Filer Materiaf{Be bG'1
<br /> TYPE OF SEPTIC�{WORK, NEV1f tNSTAlkA1CfON t tiFfiEPA3R/ADDF710N i i> ESTAt1CTEON �f INo septic system permitted pubk sevrer
<br /> Zi
<br /> yy 200
<br /> 4' *+,rt available YVlthlfl• feet 1 <� �' �, `':
<br /> tlnits a{ bedro0ins z
<br /> mbef p c.i
<br /> Character W depth.Of}S fast. x t ` {
<br /> SEPTIRF X- r t, T
<br /> ®
<br /> "T
<br /> t I G S P N t Q IICe to Nearest. _ :l, ii FourKfa ,Yrr . d jr fi b
<br /> •�— 0.'.^rs ,.. ,,,err, n-a..,,yu }m,�,. _•{a�...,-.r:.-. .,_,`r-: .. .;.«,...x .f,,,, _..j:: .w:.,r_s.w ?.:::. $'te -r��C�`„+«�� s. .es„t ,
<br /> LEACHING L1Nf», ,...iTM'_N ... -, Of firms. Total,leng /4ize
<br /> FILTER BED . a to nearest wattFoundationoPe+tY — }
<br /> Olsten Pr
<br /> At
<br /> SEEPAGE PITS Size Number t a L rt
<br /> SUMP - ,
<br /> $ - a Qktance,to nearest. is. Wali Founds Property
<br /> DISPOSAI PONDS� *
<br /> 1 .
<br /> hereby cerniy slier I'have prepared chin appgcsifwt and that the work witl be in aocofl�inca!A"Simi n,t:nunty or tosrexs,ftsts:lalns�and w
<br /> noise and reguiauons of tfW San.losquM°l,(icaf Heahlt Distdct } r
<br /> Borne oun►er or Ikoerpgd epprtt`s figttstunt t�erfifis"tf_ 4ti�bwinp "1 Cattih►that in the perfamttnca of thOwlDrlt tot 1MtiCh ltd 'pertitit le issued,l ielteq f+ot 1
<br /> PftYY perean ire ouch rratwtar as to bacorns sulrjsct�to workman s ion Iawti of CaGfarnia Coin s or sub-coed
<br /> � r tom' signme
<br /> cion moths f ��• its �y K04work fix which this isisattad,f Ntaq employ to woritrrran's carr+prmla= i
<br /> tf iS- b16r�• ;�Vk,Yx�r`lY i 3 �h r i S- ({- f f -
<br /> y Sir y .{ s a a r {i> r ff a 9 Y 3 r rr.
<br /> �`5- `
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<br /> The. �
<br /> •call � .�, ;dreMMte t �� •'�€� `�� �,:
<br /> S iA { sv s t kx r
<br /> ia, v n s a4-x v� F a 1�IF.pAf�TAI��I�T' �>�aa �14 s �v'�r mr a ez a tt ' F
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<br /> Agplicatbn Accepted py tyAtA r ' l4rss -.. ti=
<br /> Pit or Grout Inspection by, Date ,F Ir>speGtiar, by' " ` x Date
<br /> Additional Comments:
<br /> ❑ Stk 466-8781 O Lodi 369-3821 ❑ Manteca 823-7104 ❑ racy 83&63dli ,
<br /> Applicant -Return all copies to: Environmental Health Pemdt/Services 1601 E. H elton,Ave., P.O. Box 2009, Stk., CA 96301
<br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y OATE PERMIT'NO.
<br /> INFO _
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