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{ w- Nor , A. r 1 � !. �� ... `"-' :4PrLICf.T1ON ftla P Q /.• ' 1 � �tl: JG�OLi'. LataL +lE�LiH siST"niti Qom]-� J�� i 160 aA7Eti0'i .::E. STOC+:TG'.; C:. PFRP`iT N0. Telephon(- {2 91 465-6781 / DATE ISSUED QL to PERMIT EXPIRES I YEAR FPOM 17 7E ISSUED l ? ryr (Complete in Triplicdte) - rt Application is hereoy made to the San Soaquin Local Health District for a per-91t to construct and/or install the work herein � Ik described, This application is made in compliance with San Joaquin County Ordinance ,No. Sag forge r 18y� for well"Iipuump, f ' and the Rules and Regulations of the S. Joaquin Local Health Oistrict.//6 f'�r' CfGIs(.rJy ! �!#SCAtd !j 44 i4$.•` r Jab Address L)0�l 0ix �J Subdivision Name r ,°S Owner's Name :�.�{��- � Address 2 -3 3 IN-e S'r r. CGnCrattpr's Varve r}�,�T_63•-�-/)/A3 � License No.. aq Phone TYPE OE WELL/PUMP WORK: NEW WILL WELL REPLACEN.ENT DESTRJCT:O'i❑ - C '"' u• PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ s ». DISTANCE TO NEAREST: SEPTIC TANK ��i r LEWER L[:tES DISPOSAL ELD. PROP. L1FIF. F^ FOUNDATION AGRICULTURE WELL �'r- OTHER WFLI. PITS/SU!iPS rk a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC7I2N SPECIFICATIO'S g 0 Industrial ❑Open Bottom FJ Manteca Dia, of well Excavation . OR6mestic/Private ravel Pack Cl Tracy Oia. of Well Casing •, t1 ; v,} ❑public Other Dei toi; ❑ ❑ Type of Casing _ �42gL Y 7 f ` LjIrrigation � �Approx. EasternDepth Specifications ❑Cathodic Protection Depth or Groat Sear Geopl-sical Type of Grjut [' - (�Other C+ Surface °eal Installed y C, { S ± 'Repair Work !Sone❑ Type of Pump ��H-P, ]r a/� State Work Done r -�� Q Kell Destruction ❑ Well Diameter Staling Material (top 50'} 3r Depth Filler Material (Below 50'] — - "43 TYPE. OF,SEoTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No Septic tank or seoDage pit permitted if public Sewer is Y' available within 200 feet.) sr Installation will serve: Residence _ ComnerCial _ Other -�(y Number of living units: Number of bedrooms _ Lot size { Character of soilto a depth of 3 feet: Water [able depth f{ SEPTIC TAIIK ❑j Type/Mfg Capacity _ N�. Compartments s - _ PKG. TREATMENT PLT. ❑ Type/Mfg _ Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Founoatics _ Property Line '' DESTRUCTION ❑ __ _ s. LEAC1i1NG LINE U No. & Length of lines Total ienoth/size P} ? S'r FiLTER BED ED Distance to nearest: Well _ Foundation Property Line — _ G,d r !ti SEEPAGE PITS ❑j- Depth Size _ NumE?r SUMPS Distance to nearest: Well - foundation � Property Line DISPOSAL POIJDS ❑ ' ''�`. >_ i hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin county f -;, ordinances, state laws, ar.d rules and raguiatioas of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the rollowing: "I certiry that in the performance of the work for wh',;h this permit is issued, I shall not employ any person in such manner as to become subject to workr-pant compensation laws of California." _ ContraCtor's hiring or, sub-contracting signature certifies the folio Ning: "I certify that in the perforn�ance of the work far rhich this permit is issued, I sLell employ persons subject to wprknan'; compensation laws of California." The ap;lica�r st call for al] ire Inspect ns, Complete drawing on reverse side. 1 el / 1 ,� 51gne.",1k _ __ � __ Title: __�� Date! ENT USC,ONLY f r Ap nation Accepted y � Arca f�H �/1 5tk 46E-5:8 !1 ii Addittural Comments: ❑ Lodi 369-3E21 .Gt„ y Pit or Srout Insprction b +t T _ Date �j=/+,f? ❑ Manteca 823-7104 A_ Final Inspection by Date __J7Tracy 83S4385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. iiaaeltor Ave„ P.O. Hay 2000, Stk CA 95201 �+ �? FEF I BASE AMOUNT DUE AMOUNT RFM.ITTCO .RIC Ef;'EG 8Y DATE PERMIT NO. EH 13-24 REV. 10/82 3 �'�..� Nif ld�>l•/�Kf/.>��z w ' ,i; - 1=