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- 7. APPLICATiON FOR PER'•'IT 5.:.;i '�;"4til,; LDC.AL HEA:.TH Dr'TR1CT If.01 F. H3;:LLTON AVE., SIOCr.70ii, C." PERMIT NO. Telvohone (209) 455-5781 ' - PEP?:IT Et^it,tS l YEAR FROM [:.5','ED DATE ISSUED /O (Co-plete in Triplica"01 Application is hereby made to the San Juaquin Local Health Oist:•icr `or a .erd t to rnnstrnct andl)r install the work herein described. This application, is made in compliance with San Joaquin County Ordinance No. 519 for sawage or Na, 1862 for cell/pump and the Rules and Regula't/ions of the San oacuin Local Health Gistr,ct- Job Address !V lac- !id --- Subdivisi•�n N3^e _ Owner's Nasse i n.o6 LA Addy ts; --- Phone / a i Contractor's Name —� License No. Phone # .'� �r}-�,�}jTiFi-s7l'LTS-rl'-S=Fri-r f I�L✓F�I�Jf�' TYPE OF WELL/PUMP WDR!:: NEW WELL WELL REPLRCfIdENT u DESTR,JCT[[;N F] i•LH? INSTALL,T10N Ii SYSTEM P.EPLIR ;^J OTeIER J +r 4 STANCE TO NL-REST: SEPTIC TANY. cCWER LILACS I)ISPCSI+L PLD. _ FRCir LINE f u' FOUNDATT07l RGRICULTUP.E WELL ;dF EP, JT i.L _ PITS/SIIMPS ?' INTENDED USE TYPE OF WELL PRQBLEM AREA CONSTRUCTION SPECIFICAT10% I� Industrial (_1Oprn Gottom �IManteca �.a. of WeIi Excavation L DdmestiC/Private I—Gravel Pr,k Tracy "La. of Well CaSi. � s Public �iJ Ocher DI J Irrigation Type of Casing Irri g _r1^froz. �Eastern til Cathodic Protection Ce,th Specifications __ — i ❑GeophysiCal Depth of Grout Seal Other F5'pe of Grout j StrfaCc Seal Installed by §r4 Repair Work Done❑ Type of Pump M. s _ _ St:,te Work Done r Well Destruction Well Diameter 1 { . S: LI � Sea in! Ma,erial (top St"} v Depth _ rillcr Material {!I O'J '� T—�J�I-�7r]iCUaV'*'�'��'�%'L�37Xi�tF1•.'-Sdx !`_rF.Yk]Or_'9L�1.'{h�EXF �t TYPE OF 5'FPTIC WORK: NEW iNSTALLATICN CF REPAIR/Ar,DITION (No Septic tank or seepage pit - � permitted if public sewer 1s r z Installation will serve: Residence Comnercizl _ Other available within 200 feet.) 1 �.� y4 G��r Number of living units: �_ Numbar of bedrooms Loi Character of soil to a depth of 3 fee*: � �� _ Water table depth 3PFTC TANK Type/Mfg Capacity f(,GL! �Yy No. Compartments _s P1IG. TREATMENT PLT, LI Type.Mfg. �- Capacity _ Method of Disposal Se ptic Tankct io Distance to nearest: Well f r Foundation /e� Property Line ,S � .r� 1?�Str11Ct10I1 0 �-..�� -. LEACHING LINE $ No, T. Length of.lines Z— dY _ Total length/size FILTER BED Distance to nearest: well _ Foundation _ Property Line SEEPAGE PIIS Oepth.-'- 'Ji(ir Size _ Number SUMPS P r Distanc: to nearest: Wel; /Sa Foundation Property Line DISPOSAL PONDS nrssrrrriz ��? �?' Tom +'+fez tcrt_i�,-_:_;T_xx JkT1��r�+ ? 1 herebycertify o - t that I have r Y prepared this ations t t and that the wLoK will l done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Loe,,l Health District. Home owner or licensed agent's signature certifies the following: "[ co't4Fy that in the performance of the work for which this permit is issued. I shall not employ any person in such canner as to bcco;:,e subject to worCmanh compensation Taws of California,' Contractor's hiring or sub-contracting signature certifies the followinr,: "1 certify that in the performance of the work for which ie th's Permit is issued, I shall employ persons subject to workman's cOmpa:,saYign law; of California." a The applicant must 11 r al? required inspections. Complete drawing on reverse s,de. Signed x_ Title: L Date: 1_2 "!ENT U G+LY "•'• Ap cation ACCEpt by Area �. P, G 5tk 466-6781 Additional Co;rc ent;: _ [� Lodi 364-3621 Sw P4 or Grout InspecLlon -- Manteca 823-7104 Final inspection by '�->' tGr� Qate /2-!G -_ Tracy 835-638' Applicant - Return all copies to: Environmental Health Per'nit/Services iSUl F. i,re;ton Ave., P.O. Mx 2009, Stk., CA 95201 FEE _ BASE trQl!NT UUE AM(k1YT FE�1[7-EU —S!cLC;yCQ ay DATE �jIiI I10. ]NFO � •- - -- EH 13-24 RE'.. 10,'32 `-4 r Z) IO/82 5D0 1C-26