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t___.: • : _._.--- - . tri,� ."` } . I Sc'. .cr•t �': LOCAL 4--LTH 3:$ 4ICT 1541 E. Hs.100% AYE.. ST00,7 i• CA PERMIT NO. Te�eohone (20?) 466-6761 p,_f DATE D55uE0 PEPXIT EOP;RES 1 YEAR FROm DATE iSSL'Ei, •',r'x�f (Complete In TrSDl lta:e) -Pplitation is herrby made to the San Joaquin Local Health District for a permit to construct and/or Install the work herein .Fesc:lbed. This tDpllcation is rede in compliance with San Joaquin County Ordinance No. 539 for sewage or Ik". 1862 !or well/pump 1^. aid the Rules and P.egulati ns of the San Joaquin Local stealth District. Job ?•Idress��l S _ . Subdlvisior D•mer's Name • Address �� d Phone 1 e Contra:tor's Name (f]/lrf� License No. Phone /• 1 j TYPE OF WEt.L/PUMP WORK: NEW WELL (] WELL REPLACEMENT DESTRUCTION J ,1 a PUMP INSTALLATION (� SYSTEM REFA{R Lj OTHER � 1. 3 DISTANCE TO NEARZST: SEPTIC TAN% SEWER L1l1E5 DISPOSAL FLD. PROP, LINE FOLINDATION AGPTCULTURE k---LL _ OTHER WCLL PITS/SUMPS e " A: ti INTENDED USE TYPE OF WELL PROBLEM AREA CONSTAUCTtON SPECIFICATIONS * C] Industrial U Open Bottom Manteca 'Iia. of Well Excavation r Domestic/Private Q Gravel Pack ❑Tracy D14, of well Casing € Public Other ee r :.•.-.�i�, � [1 ❑Dolt Type of basing — j,j Irrigation Approx. El Eastern Specifications Depth ©Cathodic Protection DepDepth of Grout Seal • �3h al Geop ys 1 c Type of Grout Vit* L J Other Surface Seal Installed by Repair Work Done[] Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material (top SO') lv Depth Filltr Material (Below SO') fh�1 ( TYPE O' SEPTIC WORK: NEW IN REPATR/AOC1110N Lj (Ito septic tank or Seepage pit permitted if public sewer is available within 200 feet.) Installation will Serve: Residence Commrcial _ Other i a`f Number of living units: -- Number of b roans Lot sire 10 YTr - � Water table depth Llur.cter of soil to a depth of 3 feet: SEPTIC TANK J0 Type/Mfg Capacity A No. Compartments 11 PKG. -,1EAT`MENT PLT. [] type/Mfg Capacity TT Method of Disposal +� +Ni SEWAGE SYSTEM Distance to nearest: Well Foun:anon Property tine CCSTRUrT.. a ( LEACHING LINE No. 8 Length of linesD Total litngthlslre r'^ FILTER BED Distance to nearest: well •Foundation _ Property Line SEEPAGE PITS ED Depth ISO Sire �+ x�fi T Number SUMPS Distance to nearest: well f3J' -- faun 7atian _S 4 r Property Liney ----- - DISPOSAL PO.YDS fI 1 herety certify that D have prepared this aDplitation and that the work will be done in accordance with San Joaquin county ordinanc.". state laws, and rules and regu'ations of the San Joaquin Local Health District. Her-+e owner or Iktensed agent's Signature certifies th•f !ollowinq: "I certify that 'n the perfornance of the work for which this y i subject to wnrkmnr permit Is issued. D shall not employ any person in such srrnne- as to becomecompensation laws of Califnrnla." Contractor "D certify that rn the performance of the •rork fpr's hiring or sub-contracting Signature certi"fes the following: .which permit is issued. I shall employ De:Wn$ subject to workmdn'S L yrpersatlon laws of Catiforr.fa•' aYk`7 Tf:e applicant mu t call r all reouire ections. Complete dre..tng on reverse side. / $igned y. Tk[1e: _�(,k�&/ D-'-"' //s / el j �/ Da DEPAPTXLIT USE ONLY Area Y Stk 466-6781 ^; q,„d11�ppl Icatiorl`Accepted by ..- ❑ ' i • F Comments: Lodi 369-3621 nal C .p 1�.-gS LI ma•�teca 823-7104 ! i Grow[ Inspection by j ai IntPection by .y,w`�ly .�_._ � _ 'tc _ _7-(0._'�� Q Tracy 835-6385 wareFton Ave.. P.D. Box 2009. Stk.. CA 95?01 S Ap;llcant - Return all [oPieS to: Environmental HCaI'h permit/5e,ytc-s 160t E. —---� ---� _ r ..`!�U'+T DLC j .."�:i'I; PD:'::'E'� PECE:Y:D By FATE rER"'IE fIO, s fCC SASE _ I.- -.--.-, 6 ��- ---- i'.. CP- 10/h” 500 iz)/82 r r' i