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I <br /> pr >• -?E5 17.10. - <br /> L CJ plot. .n Tn •.ta tzl <br /> Application is hereby made to the San Joaquin Local Healtn OistriU for a permit to construct anc or install the work herein <br /> Oesc rimed. This application is made in campl'once witn San Joa4uin County Ordinance No. 549 for sewage or No. 1362 for well/pump <br /> and the Rules }qd %gulattii OrI5 Of he ayJ'� Joaquin hoca P/e(a�1�nCIS tl/r,ic <br /> Jab Address_y .a� U rY r -�/ "' �� �C� �' ion Name / <br /> Owner's Name . - •= •/ Address <br /> +J<�/� /,t i/✓J :l 1�,.!�='•t— Phone <br /> Phone <br /> Contractor's Name 004 4-l" License NO. <br /> c <br /> YWrr NElI WELL YC� DE SiRUCTICN <br /> TYPE OF WELL/PUMP WORK: � WELL REPLACEMENT <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR I I "I" <br /> SEWER LINES DISPOS PROP. LINE <br /> DISTANCE TO NEAREST: C T.tiVK .r ER WELL ? r, PITS/SUMPS <br /> FOUNOAi AGRICULTURE WELL <br /> INTENDED USE TYPE OF Wt PROBLEM AREA 'TRUCTIn-N SPECIFICATIONS ^- <br /> Dia. of Well Excavation <br /> Industrial U Open Bottom Manteca pia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ ,,f J <br /> " Public �j Other el to `•'�. Type of Casing — <br /> ` LJ <br /> Irrigation Appro G Easternfications TC -- <br /> L.' Cathodic Protection Depth of Seal 7 D <br /> h Geophysical Type of-Grout C,/7 L <br /> t <br /> U Other i Surface Seal installed by <br /> i H GLl <br /> Type of Pum F- /'� H.P. S State Work Done <br /> Repair Work Done YP P <br /> Well Destruction Lf Well Diameter � Sealing Material (top 50') Ge;.Z r,� <br /> Depth .�.> 5�t�' Filler Material (Below 50') CtIl <br /> ` TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIR/.ADDITIONI_J (No septic tank or seepage Pi availabieewithin 200c feet.) is T <br /> Installation will serve: R 'dente commercial Other / C <br /> Number of bedrooms __Lot size <br /> Number of living units: table depth Water /✓/C) <br /> [ <br /> Character of soil to a depth of 3 feet: Cap city G C No. Compartments <br /> SEPTIC TANK (� Type/Mfg CrN C' y )�� < <br /> Capacity Method of Disposal sal - <br /> „�._- <br /> / <br /> PKG, TREATMENT PLT. [JType/Mfg h� n Foundation Property Line I <br /> SEWAGE SYSTEM Distance [o nearest: Well 1.7=. <br /> DESTRUCTION - 33 t�L E <br /> 0 0 Atti k Cal length/size <br /> LEACHING LINE No. 8 length of l mos Property Line <br /> Distance to nearest: Well Foundation p <br /> V, FILTER BED ❑ <br /> Number <br /> SEEPAGE PITS T� Depth 5__ $jZe / <br /> ' SUMPS LI Distance to nearest: Well �' <br /> A Foundation / 3� Property Linz / <br /> {a. DISPOSAL PONDS El <br /> 1 have prepared this application and that the work will be done in accordance with San Joaquin county <br /> I hereby certify that <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is sued, 1 shall not on any person in such manner as to become subject to workman l; compensation laws of California'.'i <br /> Contrthi permrtsi siring or ed, Iusha11traclin,Psignature <br /> csubjent <br /> tl toewo rkmas the d sl comp nsati onowing: "I laws of tify a Californit in the a." of the work far which <br /> L Tr. applica - call for al�1,qurre spections. Complete drawing on reverse side. Oa te: _/Q—/C, <br /> -� — <br /> Signed Xyt•�'f'x"ztJ <br /> �i Title: -.yt ly[-,1-� <br /> pS��l�aLy4"nTL' 7 USE ONLY — Qj Stk 456-6701 <br /> — — - Area <br /> Application Accepted Lodi U Lodi 369-3521 <br /> Additional Comments: oat, Manteca 027-7164 <br /> or Grout Inspection 6Y �L'�— q Tracy 635-6385 <br /> Da'' ��- r'g- a5: <br /> Final Inspection by --- P.O. Box 2009, <br /> Stk., CA 95:01 <br /> final <br /> nvironr,�en•al Healtn norm,L'$ervic S 1601 E, Hazelton Ave.. <br /> Applicant - Rzturn all copies <br /> FECE1."ED By DATE PERM:T N0. I <br /> FEE 6a].i_ fifJ'.9 _— _— L <br />