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x> AF*PLfcAfi0N,(Pk PEVIMIT / n SAKI JoAf"i31i 'LOCAL I EALTFi bfsTRfG7 1601 E. HAZEL OPV AvE., STOckfoN, CA Te16phone 11208) 466-6781 PEfiM'' EXPIRES 1 YEAR O�iOM DATLO`.ISSUm (0 � W11" 4 _ (Cohiplete in Triplicate) , ' ``,''� Application is hereby made to the Sail Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is rhadd in Eotripti4hce With Sati Joaduiii Cotliity Oidinahce No:549 f6r 04iijjb of Nd: 1862 for Well/purno anis the Rutes and Regulations of the San Joaquin Local Health District-.w 41, };, a f:;j i i , -: „�l �.;a€r• 617 WO-XI Job Address :_ l �. L•J/:H 1,4L; N. •_ City. Lot Size 1 flit./. PM Owners Name _�"Address _a!�,s!9Q /��U°I�rTY ,15;� Phone L73 0 XY S Contractor �. M = Address i License No. �s" �Phone TYPE OF WELL/PUMP-,; t NEW WELL CK WELL REPLACEM T ❑ DESTRUCTION ❑ { W " N.MATiONpJMs $Y TEREI7AIfi ❑ OTHER DISTANCEJO-NEAF�Itt.SI PTIG,rANK , dAV,' SE9WER LINES i-��,' f DISPOSAL FLD. . PROP. LINE --F�UNI)AT10N AGRIGULtURE,iivELL' ()THEit'W9Ll�t� PITS/SUMPS _ INTENDED USE I• YPE OF 1M1IELL .I PROBLEM AREA ICONSTfiUCTION SPECIFICATIONS ❑ Ihdusttial ❑ Open Bottom w.w �t E] Manteca t Dia:lof Wel! Excavation _ -/ _ Dia. of Well Casing r ❑ Dornestic/private iiedraVel Pack © ITacy; Type of Casing /r?lf[„ Specifications /+>�d r €`t Public i'µry 11101her� � w t� Delta � Depth of Grout Seal t ( T ^ } i t � l - n� ype o Grout ViPlYAW- - IWlrrigalion �rok69�1-40 ox Depth 1 1 Easterh z i§urfAce Seal fnsiallbd by . __15Qs[-e Repalt Work Drone. L1 i Type of Pump H.P, State Work.Done Wet) De'structiori 0I Well Diiirndtet 'Sealing IViatetitil Itop 50'I Depth ' ;:. Filler Matiirial 116iow 601 TYPE OF,SEPTIC WORK NEW INSTAL LATIi1�1 1 Aeptic system permitted if public sewer is w m., .fir . : `... , s-:... ' ty 1; iiVailabl8 Within 200 feet.) Instaliatinn gill serve: Residence: Comml§rciel Other t d t Number of living'units `Nuin6o 61 bidrooin. € i' t Ch df Wh tis a dept,of 3 teec,-, ! ' i _p ¢ Water table depth SEPTIC TANK i d ;Type/Mfg f„ . i ¢= Capacity No. Compartments PKG TREATMENT PLT b 1. i 1 l t Method of Disposal i s DistAnili 116 how M611 .f, Foitrnifati6ii � propeitji Line 1 LEACHING LINE , i C' No ,6 Uhijth of lrnbs Total langtli!size pDsa8t k We1FltTEa sEo ) .f ot,tdbtibit. 0rt5pertyi Liiii3 SEEPAGE' PITS I V Dapfh ' L -A S12e fVumbef i SUMPS I � 1 Li �Distatic6!d FfbateWp f Welt #_ �i�Foernd'aitoh� _` < ' 06],tl y Lints- DISPOSALPONDS- i..Cl:i, 1 ; I hereby 66ttify that i hive pri§patrfd thij applicatl$ri end that the work'Will be done i#i accordaribe with San Joaquin county ordinances, state laws, and ruleg and regulations of the Sari- lbadiAh L6641 Htialth Dib'ldct 'b1 ` }9 -v i- = tq'�� - Honie owner or iiCdhsi3d egerit`s eibnatt�t6 eltifle>l Lite following:':,"I edify that in the performance of the 11Yprk fot which this permit is issued, !shall not employ any pOrson en§tit h - hner'as IS bic614 Aublii&to v ibrkman'it cornpe'nsnt'toh laws of California."Conttactor s hiring of sub-contracting signature certifies the followings S i certify that 1h M4 petfot hnce'of the woik for whrkh this'permit is issued,i khali employ persons subject to workman's compensa- tion law`s of Celifortsia {j i.: t. r1 Theapplicantust ca fai elf r tlited Inspebton Complete drawing-on riversa slda. +: i t _ j s Signed i f Itlb ( s i Date' 069 6t RIVEN USE ONLY Application Accepted by wi a1 E I } Date I ! ' Area Pit or o tnspactlon by Datil U Fins! Inspection by ata 1:72- 7 6 ' Additional Camiitents: ❑ Stk 466-6*;Li b Lodi 369.3621 .# ❑ Mantecd 923-7104A ❑'1 racer 835 8385 Applicant Ai turn 6111 copies tit EAviiatimih6l Walth l ermlt/Servicah 1601E H&zeltoii Avo., P.U. $ax 1009, Stk., CA 95201 r"- I FEE t AMOUNT bUE I' 4'"AM6UNT Awltttib CK sit Cs iGEp BV DATE PERMIT'NO. 'INFO .e. _,i-y CASH i • F#f 1321 tRFV.f K 51 117 tai l , _r— 17 Z E11142E . d t i