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Depth Size Number SEEPAGE PITS p Foundation Property Line SUMPS �'i Distance to nearest: Well — DISPOSAL PONDS 7-1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, Nome owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this performance of the work for which permit is issued, orasubn�ontract�nany ignat�rescertifiesmanner the followb�gomels�ertifybject tthat rinathe opmpensation laws of California. Contractor's g this permit is issued, I shall emplo �rsons subject to workman's compensation laws of California." The applica t c 11 f r all r ed i 5pecti_ ons. Complete ng on rever e side. �Date: Title: Signed X FOR DEPAR MEN'T SE ONLY � Area Stk 466-6781 ��cr __ A cat on Accepted by - � Lodi 369-3621 Addition - omments:,/ Date —j Manteca 823-7104 n 01 Pit Grout spettion b�- - {/ Tracy 835-6385 I Y c'- z:. Date r i Final Inspection by �` Applicant - Return all copies to: Environmental eaith Permit/Services 1601 E. Hazelton (ale., P.O. Box 2D09, Stk�C95201 �A �!PERMIT NO. FEE BASE AMOUNT DUE D" REMI?TED RECEI',EO BV DATE INFO ` Sri �Li-lacryD'; I EH 13-24 REV. 10/82 14-26 10/32 500 'LTd KICK PERMIT NO. v�6-� R1 ISSl1ED Telephone t%O - DATE PERMIT EXPIRES 1 YEAR FROM DA'E ISSUED (Complete in Triplica_e) rein td oaNNo, 1362re 549forsewage sl the SanLOcelwithlth forwell/Pump Application is hereby TadetoieNo. inoaquin SanDistri�''.oa4ucn CountypOrdinancc described, This apR icato s made the San Joaquin Loc Health District. and the Rules and Regulations of Subdivision Name ��7� Job Address Phone Name Address Phonec=z Owner's No. 7.7 dC Contractor's Name Q ,License NEW WELL ❑ WELL REPLACEMENT DESTROTHEUCI R u TYPE OF WELL/PUMP 14ORK: �---- �I SYSTEM REPAIR OTHER NEAREST: PUMP INSTALLATION PROP. LINE SEPTIC TANK SEWER LINES DISPOSAL FLO. —Ic2r _ /�7 PITS/SUMPS DISTANCE TO WELL IE OTHEP.1tiDLL _` FOUNDATION _ AGRICULTURE E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t INTENDED US Bottom 17 Manteca Dia. ofWell Excavation Industrial pen Oia. of Well Casing e5tic/Private Gravel Pack L�-Tracy ^ ^ El Public [1 Other U Delta Type of Casing [—j IrrigationApprox. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal U Geophysical Type of Grout Surface Seal Installed by — L J Other Pum State Work Done H. P. ?�- - � Repair Work Done � Type of , TYP p •r - -- Sealing Material (top 50') Well Destruction LJ Well Diameter _—_ Depth r` i Filler Material (Below 50'] L', REPAIR/ADDITION {Plo septic tank or seepage pit permitted if public sewer is available wii;hin 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION Installation will serve: Residence Commercial � -- Other Number of living Lot size �� units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No, Compartments r SEPTIC TANK V Type/Mfg Capacity Method of Disposal - PKG. TREATMENT PLT. D Type/Mfg Property Line Foundation SEWAGE SYSTEM � Distance to nearest: Well - DESTRUCTION Total length/size — LEACHING LINE a No. & Length of lines property Line FILTER BED U Distance to nearest: Well Foundation Depth Size Number SEEPAGE PITS p Foundation Property Line SUMPS �'i Distance to nearest: Well — DISPOSAL PONDS 7-1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, Nome owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this performance of the work for which permit is issued, orasubn�ontract�nany ignat�rescertifiesmanner the followb�gomels�ertifybject tthat rinathe opmpensation laws of California. Contractor's g this permit is issued, I shall emplo �rsons subject to workman's compensation laws of California." The applica t c 11 f r all r ed i 5pecti_ ons. Complete ng on rever e side. �Date: Title: Signed X FOR DEPAR MEN'T SE ONLY � Area Stk 466-6781 ��cr __ A cat on Accepted by - � Lodi 369-3621 Addition - omments:,/ Date —j Manteca 823-7104 n 01 Pit Grout spettion b�- - {/ Tracy 835-6385 I Y c'- z:. Date r i Final Inspection by �` Applicant - Return all copies to: Environmental eaith Permit/Services 1601 E. Hazelton (ale., P.O. Box 2D09, Stk�C95201 �A �!PERMIT NO. FEE BASE AMOUNT DUE D" REMI?TED RECEI',EO BV DATE INFO ` Sri �Li-lacryD'; I EH 13-24 REV. 10/82 14-26 10/32 500