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r , 5 t ' D:i,-'^ICT IVAI ►-. 5501 L, a_ELtOi »':E., S`QLi'%.t, ;A PrwlT NO., q- Telephone (2091 6E6-51Di DATE ISSUED . ?oto PERP,IT EMPIRES 1 YEAR FROM DATE ISSUED 1 d F i (Complete in Triplicate) Application is hereby rode to the San Joaquin Local Health District for a permit to construct and/or install the or No. 186622 forr well/pu+:� ell described. This application is made in Compliance Witt+ San Joaquin County OrdSnance No. 549 for sewage fa i and the Rules and Regulations pf he Sart Joaquin Losol Health District, ` Subdivision Name } a ICD Address Phone Owner's Name Address License No. 7 Phone fi Contractors Name ¢ F TYPE OF.WELL PUMP WORK: NEW WELL [ WELL REPLACEMENT fel DESTRUCT[ON(=J ! _ gg • � °= - PUMPOTHER INSTALLATION �] SYSTEM REPAIR Cl � ` DISPOSAL FLO. PROP, LINE y DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES PITSJSl1MP5 w.' FOUNDATION AGRICULTURE WELLIle OTHER WELL t l �'%rt' rW INTENDED USE TYPE OF WELL PROBLEM AREA CDNSTRL'CT[7N SPCCIFICATIONS �r { 1 h Dia, of Well Excavation �' ',' Industrial U Open Bottom ❑Manteca Dia, of well Lasing Domesticipeivate ❑Gravel Pack ❑Tracy, Q Public ❑Other ❑Delta Type of Casing O ` Irrigation A PProx, ❑EasternSpecifications sDepth GthodlC.Protection Depth of Grout Seal GeophyticaI ray Type of Grout Surface Seal installed by , .. 0 Other ' State Work Done "siepeir Work pone❑ Type of Pump N.P. - F y 1, Well DestrucCion❑ Well Diameter Sealing Material (top Sfl') 1 F Depth _ Filler Material (Below ro') r d rl W REPAIR/ADDITION (Ito septic tank or seepage Pit permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION (:I U. available within 200 feet.) lntallation will serve: Residence Cyamercial Otherfan Number of bedrooms Lot size s �• s Nuk er of living units: Wate^ taole depth r 0he111cter of soil to a depth of 3 feet: _ Compartments A,. T Mf Capacity 9EPIIC,TAiIK. ❑ Type/Mfg Capacit Method of Disposal . x r :• PKG. TREATMENT PLT. ❑ Type/Mf9 Y ax "SEWAGE-SYSTEM �' pistance t0 nparesL: Well Foundation _ Property Line ,,,.j DESTRUCT ION i Total length/Size -- • tLIM14ING LINE ❑ No. 8 Length of lines Property tine FILTER BED ❑ Distance to nearest: Well Foundation { P Number Depth � 5 Size 3�.. -�----'-- SEEPAGE PiTS ['J — � Property Line`— 5i1MP5 U Distance to nearest: Well ffaundatian P s DISPOSAL PONDS [) I Hereby certify that .I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. nce of the Rome Owneit isrior ssuedcensehall�u[seme signature Penpnien suchs the fmannernas to becomeythat subjectntohworkman�compensationwlawsfaf California." Contractor's hiring or sub-umtractirg signature certifies the fallowing: "I certify that inthe performance of the work fpr which this permit IS issued. 1 shall employ persons subject to workman's compensation taws of California."li4 Y The applicant now call for all r ired inspections. Complete drawing on reverse side.R Date: Y Signed % • _ Title: — `�� ❑ l k JEPARP -E T USE ONL • - 5tk 466-5 Application Accepted by _ Area a'l � � Lodi 369-3521 Additional Coneaents: - Manteca 823-7104 Pit or Grout Inspection by Date _ L .� Date ��y may❑ Tracy 835.6385 Final Inspection DyNarrlton Ave/ P,n. Boz 2009, Stk.. rA 45201 i Applicant - Return all ccple to: Environmental H�th rmit/Services 1601 E. - + r T RECEIVED Eiv W Y!pATF� PEPMIT N0. ) FEE BASE AMOUNT DUE AMDUNT RLM1t n :01A? 506 1=H 13-24 REV, 10/82 14.26