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relephone (209) 466-6781
<br /> ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> (Complete in Triplicate)
<br /> Application is heiaby made to the San Joaquor, vocal Health District for a permit to construct and/or install the work herein described.Tics application is
<br /> made In compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin
<br /> Local Health District.
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<br /> WAg, Address; ji
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<br /> "` , ` Address 42,An;. �', ,, '`t ' _kMWE
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<br /> _,#M PE OF WELLIPUMP.a v, ,�NEW.WELL � �� ��4�° WELL�iEP)AC,�MENT � � OEST��JOf70N
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<br /> q' PUMP INSTALLATION b SYSTEM REPAIR 0 NEH C1
<br /> .T bI TA1NCE TO NEARES,#
<br /> SEPTIC TAMC t 9f MITSISU fA LINESP FLA"yipFOUNDATION �': GRiCUI.TURE WELL OTWEif1iHEL1 tPS
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<br /> INTENDED USE TY PE 0 -WELL PROBLEM AREA , CONSTRUCTION iii ECiFICATipNS i r 4#
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<br /> D indulMai C]Open 13dttorlt D MantecaOle of Well Excavation .,.,._ �f 1(11 '
<br /> " I~I DtNrtBatlCXPnvata s1xC�Gravel Flack CI Tracy 'Type of .
<br /> i T Other " f1 Delta 'Depth of Grout$"I; � or
<br /> I F Inigaidon ,{,� n Appr , Oepth 1 1 Eastern Surface Seal installed by
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<br /> 'TYfl llwlf%SEES 11 { y
<br /> AW4NSTALLATIO41 1 M EPAIRl14#?f?tTION I f� VESTRUCTL 10 1 1`iNa septic syatA�rpriuTrerrt►ttt,
<br /> °available!MtilNr � 4.r�
<br /> .,, 'r tit#taNati�i'�itsttie" Resldeltca� C01nft1arCttl) "tP•'little( .,.. � � � '"`$� k '�.; 7 y ��� * �
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<br /> Character Of sato o-� '" ^m"-�• ra m g sk.
<br /> depttlx ofd(sett, a pre' _ r tabtedeptltY}
<br /> SEPTiC""TANK`. :` f ` Type!liAfp
<br /> PKG.TREATMENT PLT. O` Method of, isposa
<br /> Distance to nearest: Well Foundation Property Line
<br /> LEACHING LINE ❑ No. & Length of Ones Total length/size
<br /> FILTER BED D Distance to nearest: Well _ Foundation Property Line
<br /> SEEPAGE PITS I I Depth, Size Number
<br /> SUMPS- ❑ Distance to nearest: Well Foundation Property Linen:
<br /> DISPOSAL PONDS O
<br /> 1 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
<br /> rules and regulations of the San Joaquin Local Health Diltrict.
<br /> Home owner or licensed agent's signature certifies the following:"i certify that in the performance of the work for which this permit is issued, 1 shall not
<br /> omployany person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring ix sub-contracting signature
<br /> cortifiea the following:1 certify that in the performance of the work for which this permit Is issued,1 shall employ parsontsubject to workman's compensa-
<br /> tion Jaws of;
<br /> California."
<br /> =•Th#applicant mtgI,pa for Ail required Inspections. Complete drawing on rever"'side.
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<br /> ilv.-._ f �Signed Title: Date: I
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<br /> FOR DEPARTMENT USE ONLY
<br /> Appiicatlon Acceptacl,,by,. ..__.,._.,.; , t r~'"" '1 Date ..„ ` w Area
<br /> tt Rr taut.,tr►�pectior►by Data Final Inapecilgn 5Y. Data "�s
<br /> Additional Comments;
<br /> K
<br /> d Stk "466-6781 CJ Lodi ,369-3621 Q Manteca 823-7104 D 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
<br /> INfo AMOUNT DUE AMdl1NT REMITTED CASH RECEIVED 13Y DATE PERMIT'No.
<br /> ♦.EH 13.24(REV.I/n 5)
<br /> EH 14-26
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