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;:. JJ -r•• 1311 <br /> S?. GATE ISSUED <br /> 1561E w:iEl "'� •3R5_c.i 5i <br /> S�1"pno�e (?0,1 <br /> p_Pv,tT Ej,P;PES 1 rE.a FkOv, t5_l:� <br /> Triplicate) iwe rptk herell/P!� <br /> (co-*, in <br /> in ruct art6/dr tnsta► 1862 for <br /> Health District for a Cer^1t to cortSt5`.9 fcr sewage Or <br /> the San Joaquin local Ordinance NO <br /> Appticetion is herebydeotols wade in c)r"iance with San h Distn county <br /> described. This a'D "a- <br /> d <br /> phone <br /> and the Rut es and Rnengulawtions of the San Joaoutn local "31 Subdivision Na�.•e <br /> Job Address � TI45y Pine <br /> O.Mer's Name 1 1 0 * •F� License No. pQ <br /> contractor's Isame�� - , ❑ DES-klCt:0 W <br /> NEW Will [] WELL P.EPLACEyENT OTHER U <br /> TrLINE <br /> Py ELIC K' SYSTEMSEWER. <br /> REPAIR L PROP. UMP <br /> p�tp INSTALLATION ❑ DISPOSAL F10. -..�--PITS/SUMPS _ <br /> SEWEP. LtNES 01HE1 WELL <br /> DISTANCE 10 ,EARE' I SEPTIC TANK�___ AG WELL _�-- (.! <br /> FOUNDATION conTRUI _, SrECiFt� V" <br /> PROBLEM VIA <br /> iNTEN�SSE �'E 01 WELLManteca O'a. of well Escavation _ <br /> Open Cotton C] Dia. of well easing <br /> �]Industrial O Gravel Pack ❑Tracy <br /> Lj Domestic/Priv to ❑pelta Type of Casing �— <br /> ❑Public [-j Other <br /> ADGrdr• IEa. Sc^c�`icacions <br /> irrigation —tkt,tn Depth of Grout Seal <br /> ❑Cathodic Protection Type of Grout <br /> Geophysical Surface Seal installed by <br /> ❑Other State to.xk Done <br /> T of Pump N.P. -� <br /> Repair work Done <br /> Type — + 2, W2+pal-K-138 -m C7 <br /> Well Diameter " Seating Material (top SO'i f' <br /> Well Destruction Filler Material (Belot- 50') <br /> D"-pth�2*--- <br /> TYPE OF SEPTIC WORK: NEN INSTALLATION[! REPAIR/ADOITIOt LJ (iso septic tank or seepage pit <br /> i available within 2W00 feet.)itted if ic Sewer 13 <br /> Co�m,ercial Other�- <br /> installation will serve. Residence_ <br /> Number of bedrooms Water table depth <br /> Lot size <br /> Number of living units: <br /> Character of snil to a depth of 3 feet: capacity NO Compartments <br /> SEPTIC TANK 0 Type/Mfg Capacity Method of Disposal <br /> PKG. TREATMENT PLT. p Type/Mfg Foundation Property Line <br /> SEWAGE SYSTEM ❑ Distance to nearest: Well <br /> DESTRUCTION <br /> ❑ No. b Length of lines Total length/size <br /> LEACHING LINE property Line <br /> FILTER BED ❑ Distance to nearest: Well foundation <br /> [j Depth <br /> SEEPAGE PITS Size NunberFoundation Property Line <br /> SUMPS ❑ Distance to nearest: Well <br /> DISPOSAL PONDS L1 <br /> I hereby certify that I have prepared thisrequlat/onsatien oi and <br /> dae at the nrLocaliHeall lth District. <br /> done in tcordance with San Joaquin county <br /> ordinances, state laws, a <br /> Hone�wn!r or licensed L'3 Signe or which this <br /> certifies the following: "I certify that in the performance osationwlawsrk fof California." <br /> Peru is issued. t hal of employ any rson in such canner as to become subject to wdrin the kmanS Canpen <br /> Puntrector's hitt or sub- ratting si "t S bjec i stheworkranoslowinensatton laws of Calttornia'for+nanee of the work for which <br /> this permit is ed i S 1 loy <br /> li c e 1 f r in on pleted�p�inq An rf- el sid 28 NON 1983 <br /> The app Tine: Y a ar Wel Date: <br /> Signed x <br /> OR CE RTMENT USE ONLY Area a� (� Stk 466-6781 <br /> Application Accepted by Lodi 369-3621 <br /> Additional Comments: DateL.1 Manteca 823-7104 <br /> Pit or Grout Inspection by 0 Tracy 835-6385 <br /> Date �=-y-s� .. C„ 95202 <br /> Final inspection by <br /> Applicant Return all copies to: E"�e"ul Health Permitl5ervfces 1601 E. Hazelton Ave., P.O. �x PERMIT N0. <br /> FEE BASE AMT DUE <br /> OUNA}�ptsNT REMTTTED P.ECEIYED BY oaT= <br /> 11 <br /> 3— <br /> iNFO <br /> 10t82 500 <br /> EH 13-24 REY. 10/82 <br /> 14-26. <br />