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1 ltl-YLIt'A]Iurf I'I)li 11LIlrVgl I { SAN .I0A00IN I..0CAL IWAt.`#"H DISTRICT ,S liiT)7 I;. #-1AZf.-','#ON AVE,, S I OC#t TON, OA .. r: #t4lt}I>f1t.a'rter li�tlJl �iHi;i•fi7Si? ' F* FI IVI I'F' Fd X P i R e S 1 YEAH h 1110 PA t A f lr I14i$t1 C b Dti5 1 ^ } iCt�r�ll.tllitcf in 1'riplit;utf)). ._..`.._ .._.. 113 �pCAH A�H DIVISION Application is hereby made to the San.Joaquin Loral Health District for Va permit to Constr C��,�$� made H compliance with San Joaquin County Orrlrnancer No. 549 fur waS1u or No. ftib2 to Md�� rert � �This application is � Local Health District. ttoil�t �tF�1 nd'Ft`epulations of the San Joaquin x Job Address x 150' South Of LL7ttglas & 20- 1 S 'of..�.aoit c City_Sto ktM - Lot Size PM Owner's Name �. - A W1Ckl Ct11_iOJ. Address Addr _1765 r�1allt� _ �j Phone (916) 921-1104 Contractor Vbstexn CSO- Address 1396 E. Bawer St. yy�l� License rt13857 Phone(916) 662-4541 TYPE OF WELLlPUMP_ NEW WELL D WELL REPLACEMENT 0 PUMP INSTALLATION L7 DESTRUCTION SYSTEM REPAIR Ll OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK _ A — SEWER LINES -SO—, — DISPOSAL FLO. WAN A FOUNDATION NSA �A N PROP. LINE _-_ - _AGRICULTURE WELL OTHER WELLM b= PITS/SUMPS NSA l INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS C] Industrial !.I Open Bottum I.] Manteca Dia. of Well Excavation Ma 0 Domestic/Private IN Gravel Pack Dia. of Well Casing, Il Tracy Type of Casing��_ f'l PublicSpecifications ! l Other Ail (Delta. Depth of Grout Seal r E r I I Irrigation Approx. Depth I I Eastern Type of Grouill�} Surface Saul Installed by Repair Work done LJ Type of Pump H.P. Well Destruction 11 Well Diameterr` State Work Done_ Sealing Material Itop 5D') % Depth 65' Filler Material (Below 50') {30.__) TYPE OF SEPTIC WORK: NEW INSTAt.LATION I I AEF'Al7 RlADDITION I I DESTRUCTfON I I tNo septic system permitted if public sewer is �._ Commercial ^ Installation will serve: Residence available within 200 lest.} r Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: SEPTIC TANK (_,) T Water table depth e ype/Mfg -_ - _-- Capacity_ _ No. Compartments f PKG. TREATMENT PLT, i1 f Method of Disposal Distance to nearest I _ Foundation _-- - ° _ Property Line ' a: LEACHING LINE Cl No. & Length of Ii es --- - Total length/size_,_. FILTER BED F] Distance to nearest: Well - _ Foundation _ Property Line J + SEEPAGE PITS I I Depth P Number SUMPS' l I Distance to nearest: wr:u LL I FOrrrlrtifliOn _ _ Property Line DISPOSAL PONDS I I hereby cartify that 1 have prepared this application and that the wt>tk will bu dr,ne in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Disuir.t. ' Home owner or licensed agent's signature certifies the followirig: -I certify that in the performance of tho work for which this permit is issued, I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractin11t F Certifies the following: "I c rtify that in the performance of the work for which this permit is issue a g sigt� lien laws of California." �A� The applicant mu all fo a ct' n Compiete drawing on reverse silo. ENVIRONMENTAL_ HEALTH DIVISION Signed x Pr� idm SPECIAL PE —_� Title: __ es - Date: ;gg FOR DEPARTMENT USE ONLY Appli ' n Accepted by — ---- --- — --....---.-_ Date Area Pit or Grout Inspection by Data , ---��_ Final Inspection by Date r Additional Comments: 0 Stk 46&•6781 L7 Lodi 369-3621 D Manteca 1323 7104 i-7 Tracy H35-6385 E vrcbs 1601 E. Hazelton Ave„ P.O. gox 2009, Stk„ CA 95201 Applicant - Return ail copies to: Environmental Health Permit/Ser a TEE AMOUNT DUE AMOUNT REMITTED x tr INFO RECEIVED BY DATE PERMITN0. � EH 2�iREv,r�wet W EH 142E