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A_ PLiG�L1'ttl0�[_FOR'f�E ftM9T / SAN JOAQUIN CAL HEALTH DISTRICT 1601 E. HAZ>=L f ON AVE., STtJCKTON, CA Telephone (2091 46th-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Coinplete in Triplicate) J T J T ;w Application is I:,:reby made to the San Joaquin Local Health District for a permit to construct andlnf Install :!ie work herein described.This appfcatipn is {• made in complianco wi!h San Joaquin County Ofdinancu No.549 for sewage or No. 1BG2 far well/pump and the Rules and Regulations of he San Joaquin . .: Local Hcahh 'J'suicL Lot S;ze PM Ci Job Address t t_l /t t t �_� �- -- y Address - 7�7 am u' V }rte A Owner's Nornu Phone-- --- t Contractor_+` Address f (i,.ern r��'/t�Lilense No. Phone '�1 } TYPE OF WELL/PUMP: NEW WELL 1.1 WELL, REPI.ACEMFNT i_l DESTRUCTION I-� PUMP INSTALLATION Cl SYSTEM REPAIR CI OTHER .,y,tiE3 DISTANCE TO NEAREST: SEPTIC 'i ANK _- - SEWER LINES �---- [?ISPOSAt PLO.__.,____ PROP. LINE ttr `LF r - FOUNDATION AGRICULTURE WELL __ OTHER WELL PITS/SUMPS _- INTENC'_O 115E TYPE OF VVELL P908LEM AREA CONSTRUCTION Si'FCiFiC.,TtONS E1 Industriai CJ Open Bottom G Manteca Dia.of Well Excavation._--_—__ Dia. of Well Casing I-] Domesti"/Private Li Gravct Pack CJ Tracy, Type of Casing—___ Specificalians I'] Pubiic I.1 Other 1 Delta Dep0i of Grout Seal __.—� Type of Grout_-- MC ! I Eastern Surfaces Seal Ins[allud by c ' Rapair.Ww' Done LJ Type of Pump __._--._— H.P._ ________—_—_—� Srata Work Done--__ Weil Destruction ❑ Well D'%meter -__ __— Sealing Material Itop SO') ? r:, Depth ._.___.—__--- Filler Material IE3alnw 64'Y -- Y TYPE OF SEPTIC WORK: tJFW INSTALLA MN I HCPAIRIADDITION E I DLS7RUC71f),y i I {fin septic system permitted it public sewer u availabire w+rhin 200 feet.) P Instaflalion will 5."rve: Residence-/1- Con7m01C61_.._._ Other f tV M' r Number o.1 living units:__Z__ Number of dedroorns.. Character of soil to o depth of 3 feet: -tk.._.___ -.- - _ _-_-___.----bVa[er nable depth 3 SEPTI::TANK t_7 Type/Mfg �rti� t?_�/�_-_,Y_r��--- Cal,ac tY--��t_��C`_- No.Compartments PKG. TREATMENT PLT,C] 1 �� Methcd of/D posa I Distance to nearest tirleG-1.! _ Foundation_f _ Prnperiv Line F 11f LEACI:ING LINE IR No &Length o1 linos ---._':.--- —_� .--__ _ data lenpihlsize_—__�/C� KT FILTER BED ❑ Distance to nearest. Wral _�- -_ Coe:n.fatic � rf f P,operly Line .C. ----- - - - ---_..�. -- - * SEEPAGE NTS f Depth ---:7r Situ _ _ _ ___ Nvbur _�,---- { SUMPS I_) Distance to cearast: Wel. _,�✓{�r :t:url!falion— � Property Linu DISPOSAL. PONDS ❑ E hereby cortil,that i have preparud this'.tpplicatio,�and that we work vA!l be done in accordance with San Joaquin county ordinances,state laws, and 5 u rules and regulations of the San Joacµ,6 1_ocae Hta;th 01S Ct. Horne owner or licensed agent',:signatom coni!io:,the fnllowin4: "{certify th;rs in thn rxtfformance of Lha work for which this permit is issued,f shall not emp}oy any;>arson in such manner as to becomn subject to workman's compa�rsauon laws of California."Consrar-[or's hiring or subcontracrr,g signature r }[[[}}} certifies the following:'9 certify that h,the performance of thu work for which this permit is issuod,I shaft umpl•.y persons subjoct to workman's compensa-tion laws of Calif The applic�.ni rn��call for a31 quired i,zsr uti:lns,Com ddrr ing nn/r:varse side. Date: FOR DEPARTK. ENT USE ONLY e Applicsbon Acceptod by Date Area— t_ Da,o— Final Inspection by—_--" . D a t 6 !,1 ' Pit or Grout Inspnctiar,by —_ T�_-- _-_-- Additions!Conornnnts: — — — -- '� n StE ?66-6781 0 Lodi 369-3621 LJ Manteca 823.7104 C-3 Tracy 835-6385 Applicant•Return all copies to: Environmonta!Health Permit/Services 1601 E. Hazelton AVO., P.O. ©ox 2009, Sik_ r 9t3201 y� k" _ ,FEE t AMOUNT DUE Af,AOUivT REI.);?TEO Ct.t, RECEIVEG BY DATE PEFMIT'NO. -� - �J `•� ASH EH 13-I4 LAM EH 14-26 L