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C LOC L nE .in i 1001 E. n _iLT' ii }`' Teletr.one'{2O?' 466-G 7`i J4 ,i ➢EFvfi EYP;F:S ! kE� FRDx C„Ti c D',SE ;SSUEC /- _..��-- (Co-plete In Tr;plicdtel v ;+ Application is hereby made to the San Joaquin LOCal Health Cistrtict for a pe mtt to constru lect .3nC/.,r install the .urk herein described, This application is made in rom,liance w to S n i and the Rus and Regulations of the San JoaquinLccal realLOdquim County Ordinarce %Q. 549 rcr sewage or Np. 1362 'or well/pump }S ' Job Address 6, Owner's Name ___�Subdivision ;lame - 2 Aadress mss' - Contractor's Name - Phone i L:cer.se ':o, �- -e Phone T TYPE OF WELL/PUMP WORK: NEN WELL WELL REPLACEMENT 1� r 1 D_STRUCTiOIr�, f PUMP 1HSTALLAIiON (J SYSTEM REPAIR DISTANCE NEAREST: SEPTIC TANK IJ OTHER J'F SEWER LL'�E5 DISPOSAL FCC.a I FOUNDATION WELL - PROP, LINE f AGRICULTURE WELL OTHER WELL PITS/SUMPS ! INTENDED USE --� TY^E OF WELL Industrial PROBLEE„M z5C0',STRIlC11DN SPECiF:[1Tinl,S_ -. _ LJ Open Bottom Manteca Did. of Well Excavation LJ ;. Domestl:/Private Q Gravel PackTrac 7 Public �j Other ❑ y Dia. of Well Luing O []Delta (f Ljlrrlgatlon Approx. Eastern Type of Casing ¢¢ I ❑Cathodic protection Depth Specifications Geophysical Depth of Grout Seal '1 L]Other Type of Grout - a Repair Work Done Type of Pump H P Surface Seal Installed by \3 z Well itstruction U —�� State Work Done Well Diameter Sealing Material (top 50') ;s 1 � Depth Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION (.� (No septic tank or seepage pit permitted if public Sewer is II available within 2DO feet.) Installation will serve. Residence _ Commercial)C Other A 7 Number of living units. Number of bedrooms Lotsizea' Character of soil to a depth Of 3 feet: CL.4 TANK y SEPTI ' Water table depth �a C. �J Type/Mfg Ca acct PKG. TREATMENT PLT, -- p y No,` Compartrents SEWAGE SYSTEM Type/Mf3 Capacity Method of Disposal - 3 , DESTRUCTION Distance to nearest: Well Foundation Property Line { LEACHING LINE [J No. S Length of lines E _ Total length/size FILTER 8E0 Distance to nearest: well Foundation Property Line '. SEEPAGE PITS Depth Size Number Z 1 SUMPS U Distance to nearest: WeI V DISPOSAL PONDS foundation / Property Line �} �,� 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, Home owner or licensed agent's signature certifies the following: "I 'ertify that in the perfplrrance of the work far which this Permit to issuedi I shall not employ any person in such manner ..s to become subject to wprl:man�compensation laws of California.” Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perforinapce of the work for which this permit is is_Ued, 1 shall employ persons subject to w The applicant must-call for al equire arkTan'S compensation laws of California." I s cLions. Complete drawn o reverse ide, Signed X Title: Date- ARTMErrT USE ONLY - Application Accepted by Area o ZI Stk 466-678I Additional Comments: J Lpdi 369-3621 Pit or Grout [nspect�on by Date — hanteca 823-7104 Final Inspection by X- Date Tracy l- y 835.63d5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 L'. Hazelton Ave., P.O. aOx 2009, Sue,• CA 95202 FEE J BASEE&40!UNT DUE AMOUNT RE!!!T1ED RECEIVED BY + DATE PERMIT NO. I INFO IiJ y}= s EH 13-24 REV. 10/82 v 14-26 10/32 500 M�•o 14 i c'