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3 L. I7'• - <br /> $ LJ _ S i <br /> 1G �H .TG'+ i L S TJ �T :v, PERM'T NO, <br /> Telephone (7091 4ec_;7 <br /> DATE ISSUED <br /> PEPYIT FKPIRES 1 YEAR FRO?: J,TE ISS'U'ED <br /> (Complete it Triplica=e) <br /> Application is hereby made to the San Joaquin Local Health District `or a permit to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regul tions of the San jcdcun Local Healt District. <br /> Job Address W 3 j,, T<Ab o :SYV-,OL) Subdiv cion Name <br /> Owner's Name E444A GANTE2 . Address64 <br /> Iti C- Phone � "(d'L�S'T <br /> Contractor's Name j:W C License No. t{.7j Phone <br /> TYPE OF WELL/PUMP 14ORK: NEW WELL L WELL REPLACEMENT I— DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER I_I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHEP. ItiELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial U Open Bottom �J Manteca Dia. of Well Excavation <br /> U Domestic/Private 7 Gravel Pack U Tracy Dia. of Well Casing <br /> Public F-1 Other U Delta <br /> Li Irrigation Approx. Eastern Type of Casing <br /> Depth Specifications _ <br /> Cathodic Protection Depth of Grout Seal <br /> Geophysical Type of Grout <br /> LJ Other <br /> Surface Seal Installed by <br /> Repair Work Done {L Type of Pump H.P. State Work Done <br /> Well Destruction L Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ' (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: -�_ Number of bedrooms ��— Lot size /ti 7 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK El Type/Mfg Capacity No, Compartments <br /> PKG, TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to n refit Wc}1 Foundation Property Lire <br /> DESTRUCTION ❑ (,( I <br /> LEACHING LINE No. & Length of lines / — `�7.1 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well �S r Foundation /99 t Property Line /e, <br /> SEEPAGE PITS Depth �!/ Size _ " Number <br /> SUMPS Distance to nearest: Well j g Foundation �l� r Property Line ! � <br /> DISPOSAL PONDS L <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which tfiis <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." <br /> Contractor's h'ring or sub-contracting signature certifies the follow4riu: "I certify that in the performance of the work for which <br /> this permit i issued, I shall emp y Pers s subject to work an's compensation laws of California.'' <br /> The app]ic t call r all wire spec ions. Compl e d on reverse side. <br /> Signed X Title: �.1 Date: ' <br /> MENT U NLY <br /> Application Accepted Area ( Stk 466-6781 <br /> Additional Comments: ' ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date y f' Manteca 823-7104 <br /> Final Inspection by %, Date &-11 �E Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0, <br /> INFO <br /> EH 13-24 REV, 10/82 10182 500 <br /> 14-26 <br />