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APPLICATION FOO PERMIT ' - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZF:.TON AVE., STbCKTQN, CA FILE COPY Telephnne 12091 466.,6781 ;� F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rGr)mfrlolr•. in Tfipirr,:lii�1) i ' ASKmlrcat+rtn.e 00"drby rrtwn o to rhe takr,Jr,nrlirrrl I f,1401 11644th il.rtr.r f inn•Ilsrmrt rli r 0#V1lrrt oodrrrr#%fag tho work hnain deacrihad, Thissoplication ia < merle 1n r ong1ti lnro wills tiRn JO4r11101(,-01011y Oftlell.144[.01 Lir, W9 iris wwalrn rrl Net I Wr7 I�ri;wrlt+iwn>fn aml rtla 1410116 and Reip"lfoM of the Son Joe" i nesl hfeefrh fIr4NKf �Q f se>i1 A - � C3 �' + �� /f 1 '+i� 1 ,ld►'.. ,r#'vl ora �� J, WA ,� Me C-Cr 1� /c- i/ X, .ddmss 1 .t' l�_ . i /� � Phone`/! Owner's Name _L!!� _.�__._tr On __�__�� Contracts_ &4ius-.dtlncsc �x License No.7= L c ��f'none TYPE OF WCLLIPUMP: NEW WELL L-1 WELL REPLACEMENT III DESTRUCTION Ci it PUMP INSTAI-LATION 1_1 SYSTEM REPAIR 0 OTHER 0 w 'ly DISTANCE TO NEAREST: SEPTIC i MirrC _ _ � SEWER LINES _ DISPOSAL FLD. PROP, LINE T FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ) Cl Industrial Ll Open Bottom Cl Manteca 1.µA 6078.-of Weft Excavation Dia.of Well Casing Ll Domest+clPrivate Cl Gravel Pack I l Tracy Type of Casing SpeciSCatiom t 1'I Public 1.1 Other 1-1 Delta Depth of Grant Seal Type of Groep I I Ini(lation —Approx. Depth 1 I Eastern Surface Seat Installed by Repair Work Done L3 Type of Nimp _ __ H.P. __ State Work Done Well Destruction 17 Well Diameter Seating Material{top 501 , Depth Filler Material tBelow 5W..) _- s TYPE OF SEPTIC WORK; NEW IN5TAI.t ATION REPAIR►ADDITION I I DESTRUCTION I 1 1No septic system pnM d red N public sawn+/Is a available widtin 200 feet.) f Installation will sews: R )dente r� Commercial Other l Number of living units: Number flied ooms eSiM Ir Character of soil to a depth o1 3 fear: �' depth �Li') Wats►table SEPTIC TANK j� TypeiMfg CP.0, 11-(_ - A Z- Capacity lam No.Camipartltaanta 1: PKG.TREATMf..NT PLT.0 / Meted of Disposal i Distance to neatest: Well Lam' Foundation 1� , Property Line Ze-92r 1 LEACHING LINE Pie—No. 8 Length of lines _ Total lengthlsi:e • 1 FILTER BED L7 Distance to nearest: Well Q._ Foundation Property Lina .I SEEPAGE PITS I 1 Depth —_Sise Number j SUMPS l I Distance to nearest: Well Foundation Plopaty Line 1 DISPOSAL PONDS I'_l i I hereby certify that I have prepared this application and that ft work will be done In accordance with San Joaquin county ordiihaltces,/tate hws,'Bnd rules and regulations of the San Joaquin Local Health District, Home owner or licensed agent's signature canifles the following:"I txrtify that In the performance of the work for v*kh this pairmill is issued,I shall J employ any person In such manner as to become subject to workman's compensation laws of Cslifamie."Centrsctoes hiring tr sub-corttrecd ig signature i cartilies the following:"I certify that In the performance of the work for which this permit ft issued.I tlledl enlptoy parsons subject to workman's obmpaltse- ill i lion laws o1 California." 1 The applicant must call t all trod the ctlor►i.C ata drawWq on 141V011114 side..w Signed X- r Title: Date: TOR OEPAR NT UBE ONLY �1/� S Application Accepted by — �� Data -Z7�" r Am /D Pit or Grout Inspection by Date Final Inspection by Deft Z7 s Additional Comments: ?`+ 0 Sik 466-6761 0 Lodi 369.3621 Q Manteca $23-7104 ❑Tracy 83644 Applicant-Return all copies to: Environmental Health PerrnitlSomices 1801 E.Hatehon Ave.,P.O.Bon 2M9,Stk.,CA 85201 �: FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY OATS PERMW#00- INFO ';r ♦EM 13.16 E11EV.r re�i U `) �}1 S�� '!• -70 4 t