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' APPLICATION FOR PE��MIT SAN :11DA(2UIN LOCAL y 4C L HEALTH DI9 ICT t 1601 F. HAZE:.TON AVE., ST06TON, CA I Telephone (209) 466-611 � r PERMIT EXPIRES 1 YEAR FRO MI�DATE SSUED (Complete in Triplicate} -�-� Application is hereby made to the San Joaquin Local Health district for a permit to const 'I made in compliante with San Joaquin County Ordinance No, �a4S for sews a or No. 1862 f� 9)�l scribed, 7h{s apetteatlon ieLocal Health oistrltt. g r and theRulesand Regulations of the Sen,Joaquin , Job Address 44 1 a ��+,�y y City ` Ept SIIB �� IoW+ a'¢LJfi�• _� Owner's Narna lh II1 I ^� II r N A�1C?.s �'�-�,�.. �r� .— Addr9sa•� � + N ' � Phone " contraclat ,±1+6 r Address , i �Q TYPE OF WELL/PUMP: ! �c License NO. S Ptfptte r +E WELL Q . ce7` 7 WELL EPLACEMENTI❑ DESTfauCTl�N Cl PUMP INSTALLATION 0SYSTf MPAIRi❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � � � PR ��f� J In DISPGSAL F1.lJ.�,,,,,, PROP. LINE „ ►�OI __. FOUNDATION _ _ AGRICULTURE WELL iOTHE9 WELL — PITS/SUMPS INTENDED tibli TYPE OF WELL PROBLEM AREA_ CONSTRUCTION $PECIFI 'ATIONS C1 Industrial U Open Bottom w ❑ Manteca Dia. of Weil Excavation � I � Ca Domestic?Private U Gravel Pack 04. of Wolf Casing C7 Tracy Type of Casing I. Specifications Public F1 Other E1 Delta _ ! Death of Grout Seail _ Type of Grout I ! irrigation 2V APProK. Depth I I Eastern Surface Seal !nstalltid Repair Work Done U Type of Pump ._... -- N.P. __�__ II btr-..-..------._- ..,. , SiaSQ Wqt Doe WL'; Destruction I7 Weif Diameter .� Sealing Material Itop 50'1 3 Depth�. - _ Filter Material I3elaw 50'J !71 "Y--L' TYPE. OF SEPTIC WGRK: NEW INSTALLATION I I A9PAIR/A00ITltJN I f DESTF0 ION 1I. fNo SdPli4 system ptarr»iS1�,cr if puh!iG sewer is available within 200 feet.) tnat$ltptipn will tcervp: FTae<idarrcp f:omnlere:iat otirerr _- Number of living units: _._,,,_, Number of bedrooins T Character of spll to a depth of 3 feet' _Water labia depth SEPTIC TANK © Type/Mfg WCapacity�r No, Compartments PKG3 TREATMENT PLT, O I Method of Disposal Distance to nearest: well Foundation Property Line �.. i� LEACHING t1NE L1 No. 8 Length of linea _ i Total lengthfsite__ _._- _ FILTER BED Dittanco to nesrrr et; Well Foundation � Proporty Lino SEEPAGE PITS I I Depth _ $Ise I Numbsir SUMPS Ll Distance 10 nearest: Well Foundation— i 'Pro -- periy Line DISPOSAL PONDS ❑ I ` I hereby cenify [he[ I have praparad this application and that the worts will be dons in aerortlance Aiith San Joaquin county ordinances, stare rules and regulations of the San Joaquin Local Health Dr3trict. a Horne owner or licented agent's signature certifies the following: "i certify that in the parlGlance ol the work for which this permit is issued, employ any person in Such rivoiner as 10 baCiDme subject to workman's componfidtion laws qj�Califorrtis."Contractoes tilting or$ub-contravin certifies the following: "I cartify that in the perlormancg of The work for which this permit is Iued, 1 shrill employ parson*autaject to workman's tion laws of California," The applicant est call/for alt required Inapactinn>a. Complete drawing On tevrefso side. 11•r� � Signed ila 4 FOR DEPARTMENT t E ! ; Application Accepted by __ __ s e '° Area Pit or Grout Infrpeeilnn by Date �..___. Fil tF TiT 1 Date Additional Corr marts: 4- �_� _fl SIR1C 0 Stk 466.6781 ❑ Lodi 3W-36221. 0 Manloca M-710 ❑ Tracy 83t�6385rn CA1 N ❑1V1='°'J Applicant - Return all copies to; Environmental Heahh Permit/Services 1801 E. iiareiton Ave,,,FEE T IWO AMOUNT DUE AM4t,NT r+CM-TT£C?� flE�>1+t€p SY GAT9 P€F�MiT�dd. EN lyal(pEv.trfif -70 d L : 2T �� C`i J li :ir ��r�' ata U131 NT h3. f34�, 1 f.