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<br /> APPLICAT�I`0NYF0 PERMIT
<br /> SAN•JOAQUINY��DCAL''H ALTH DISTRICT
<br /> ` f= 1601E HAZELTCN''AVE.; STO�KTON, CA' {
<br /> -"Teleph6ne.I2091; 1 �. :•<:,: �•` r;
<br /> PERMIT EXPIAI"841 YEAR'FROM DAT1: ISSUED
<br /> E -�a £<. .•:r� * q .) YA''n' 3�+ ai 4# Td Xf w.$$ "fin k4 a' a 't
<br /> = k ete in tri Itcatel'
<br /> Applicetign is hfnbbr rrtada ta�ths San.Ioaqulri,logal,tealehtci�for a,parrn,t eonsuuct arid�tx install.the work hereto described.This eppllcation is
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<br /> made in compilance.'t}t sen Josquln County prdinance No, for sewage or No 1862 foiinrell/pump and the Rule'ait�d Regulatla of the San JDaquin
<br /> Local Health District: i.., S"•, " :R
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<br /> Job Address ++! f nC.�a:�, ^ �F' City •�""" '• Lot Sizs PM
<br /> Owner a Name -+�G ,` yAddress • wdoiqPhojr
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<br /> Contractor,'" '" drys' "°"+• ' s.•, L:cense No Pho --
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<br /> TYPE OF WELLYPUMP --..,NEW WELL ©:.n. 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 .. "TYPE OF WELL PROBLEM AREA CONSTRU TION SPECIFICATIONS N—
<br /> ❑Industrial O Open Bottom Cl Manteca Dia. of Will Excavation M>Dia. of Will Casing
<br /> ❑ Domestic/Private *favei Pack - ❑Tracy Type of Ca sing— Specifications
<br /> f 1 Public 01m, Mi� Ot r n Delta Depth of rout Seal �- Type of Grout
<br /> I I.Iriigalion Iw/6� V pprax. Depth i I-Eastern Surface Stal Installed by__ .r fes it
<br /> Repair Work Done 0 Type 0 Pump H.P. State Work Done _ -
<br /> Well-Destruction . ❑ .,.Well Diameter Sealing Material (top 50,)
<br /> Depth ,FNIer.,14sterial I8e1o, W),-
<br /> - TYPE OF SEPTfQ WORKS �NlMiINSTALLATIbN{T. REPAIR/ADDITION 11:1 ESTRUCTION.I-•INu septic-system-permitted rf publxraeweras rt
<br /> 4 ? s yr ? z r available within 2W feertz4 a
<br /> $ N 1r {'WI�IAra Wy '#���jl�2her r. vw 6 - a +y x ;• sty r y,kiP�i #�w; '
<br /> Number Ot,kYN�Unna a ^S hlYmbariQ#�iJ4drOoirla }a r , s
<br /> r " :ry Y t "' ^v' r-ry�'+�e•, z .:�.. - < ,.�,. �s3 .--n , You.7 ram,}t fi - t
<br /> Characterdf sail w a443 feat �_>v a Water to depth °
<br /> EPTfC TANK;�Y ,"" L7f '`"', �' � r�� '; Ca f+fo° F � r
<br /> ` PKG jREATT i+ c `, s¢ �{ ...�,
<br /> ' y.Fk,, s,� :1 ,
<br /> 7h
<br /> FOune a ?rapeny Liner r , a i zf -
<br /> � ->� q..-d y�e`.c2N'�,r�-.•°y�.r :;� ,�#,�.i..�;+.1.y.�, �. ;z .-.�i .9x„ �'� .:fir �!. r E }���; a�� `s
<br /> r LEACHING LINE ❑ No 3 Length of.N ^? Total k?rn ith/size
<br /> S FILTER 8Ed t DFetan ' eat Well Founds Propertlr Llrw �
<br /> SEEPAGE P I,I""-, ,`. r Number s
<br /> ;LJMP$ z:�Frt'r . o-L�1 Dattanw to r WeU Founds' n Properly l Ines„. ;
<br /> s ,DISPOSAt-'PONDS :. -------------T
<br /> �p/ 8`FL - - H�•� ���-^�4vy, `_ _3 ,�,�,.�-....w�y4,.___,w.
<br /> T�rtily that�.1_have, ;fared this appiiria{R/�.1w t )TYPE n11F 49 - in wooKhm A th alt F i i �
<br /> rubti and regtrlatrona 6f,ft.Sero Joaquin Local'Haahh Distrit.K k g Ju n!xp! statektilvs, r
<br /> ` Hane owrtar or Iftxnasti agent's slgneturacerEf(ias tilt[akowing r'1 certMy that M psrbmtanos oft a walk for }_ #
<br /> Parlrrit Is;.lsst tt � 'r
<br /> employ any person in twch memner asfto i5gaotrie subject to rvarkrnart s cArttpertt-- laws tit Celifornis. COMractor's hMMg or wb tbrtitrtctfnp alg ttrrs y�
<br /> certifies the folbwing 'I asrtify�that in'te erftitrnanoe of to work fotwhic i this is'iewed l sha11 1pI-ft aartswbje&t so 's, trirlpen a�r
<br /> titan laws Of { G + Lyr 11r
<br /> � � E.,� � 7 $ h .,..[2� 'S ' f �_, r� -�. `� P �,� i'' � r73 t i1T;-�` � s•"g;� ��-y, cl *'� -
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<br /> Signed Y f 3k ;.
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<br /> ;` 1 ,DEPAitTMENT
<br /> BE.ONLY . I � �� I' `�
<br /> 1a'r.-.-.
<br /> Application Accepted by
<br /> Pit or Grout Inspection by pate,_ Fin l,inspilction by
<br /> Additional Comments:
<br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ racy 836-6385
<br /> Applicant- Return all copies to: Environmental Health Paimit/Services 1801 E.H on Ave., P.O..Box 2069,.Stk., CA NMI
<br /> INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED 6Y DATE PERMIT'NO.
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