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`rr�t✓ 7, yArkl JUAUUIrY LUC:AL HEALTH Dlso.;iL. <br /> M i r 1ti01 <br /> E. HAZEL T ON AVE., STOCK N, CA <br /> ' T11600.e (209) 466-678..7r_: r <br /> ., <br /> PE^.NIIT EXPIRE ''VEAR FROM DATE ISSt1E <br /> ^; a. (Complete to Triplicate) <br /> r AF r ti^n r is hereby made tt,the Sin iquin Local Health Distr-rr,t for a permit to construct and/or inst.,fl tf�e N+ork di cri ed <br /> - �,_rttaoe xi corr,piiance with Sa^Jo:Zr Cot ry Ordinance No.549 for sewage or No. 186^for well/pump and the Rule3 and Regc.>7at:Xn of <br /> �LOca(Hesith District <br /> f'v_ A_`.SILL"'ALot Size <br /> f' P., J— <br /> `"IFN <br /> �p'1U�rey3 r�Gl l-- "i=`�iL-"'��•VLr'ceen7.s No-!. -___._S_:•,�_--' y <br /> P O WELj?P.UVWj c Nr <br /> J�'WELL"I .'/'JELL REPLACEMENT i�! F5TRe1C7ION.�t. -t r;�0y <br /> T..LLATION SYSTEM REPAIR i.7. DTHER O a t`• <br /> 1 � aNK SEWER LINES �. DISPOSAD, PROP-LINE <br /> ' fJDATION AGRICULTURE WELL _ OTHER V, ! PETS/SUMPS <br /> tYPE OF WELL PROP[CM„ EA CONSTRUCTiO!iFSPECIFECATI 145 = l <br /> -_ - - - _ <br /> 1II. Open Rottom Q Manteca Dia. of Well Excavation Dia-of We-I "wig <br /> tGravc4 Pack F. Tracy Type of Casing-,-,-�--- Sp�afratKxv: <br /> t1 Jther 7 Delta Depth of Grout Se..^( -_—__ ._ Type of <br /> Dr;0) I 1 Eastern : Surface Seal Installed by, <br /> r V'cxk <br /> one C] Type of Pump _ H P State V, Dame <br /> 4 D`e'.strodnD" Welt Diameter � — Scaling Maternal Itop 50- ') -------- <br /> Depth Y <br /> 9. <br /> �- -_ Fillef Material(Below 50•i <br /> PE Of: SEPTIC WORK; NEW INSTAL L-TION I ! REPAIR/ADDITION DESTRUCTION I If" SBDtIc a',steperm.t ter]i1;xrtN�c wir"T ra'�. <br /> - m a!:IhM within 200 feet f <br /> t i T/+C <br /> InstaMt a t',' re, <br /> R, rien r. Commerc,n Other`� _-� f sl-- <br /> y <br /> Nvmhrtr of units•� Number 3f bedrooms <br /> i. ras rcr If, oto a depth of 3 f".1 �^ _—��.-_ `Nair!table dept* '_ : m.. <br /> IC TAPdK CD Type!f.lfg -- I�L� _---Capacityl�9� No Compartments -� C <br /> Cs.TREATMENT PLT.Cl Method of Distrnal <br /> Distance to nest <br /> are : V"v Pi!_ �.--. Foundation__.—_ Pr,;;erty Line --- <br /> (Cj .Total <br /> F1 Distance To noerest: "'Pit�_ _-_Foundation _._- P-perty Line _ _- = • p� <br /> 'EPAf�, r fTS - Depth_ -" S re _ -- -- -- aurrber <br /> SUr:1PS r [ D,stance to nee,est: : Well Founda[io t _ - P,.perry.;ne <br /> PC.`_`At_PONDS f 7 --- <br /> ,`Crtify-,that l have prepared this application and that the work will by done in accordance,w;t:- San Joaquin covnf-o,dirvtnces•state Sawa,and <br /> x,+gulaYons of the,San Joequin Local Health District. <br /> nsed agent's signature ce tifies the foflow ng:"I certify that In the performance of v" work fcr which thts permit rs tffuedit full not <br /> 'In such manner as to become subjer:t to workman's compensation laws of Cal forn:.e Contractcx's hiring o, sub-coribacting SWI fi+e <br /> '"I certrty thar to rho perfonnance of the work for which this permit is issued,I shat-employ persons subject to Workenan'a currtge"r+ss" <br /> Nil { <br /> for all required rsnecllons. Complete drawing on reverse side. • n - <br /> _I_7 ___- <br /> _, _ _----.----- Title:_L�'l!_1_�'Lf� _-... <br /> . ld _�_l_`--- ---__.� De'e <br /> - FOR DEPARTMENT USE ONLY <br /> ed hY _ ___..___.___.__...-...-_-__. __.-..._ Data_ r Area <br /> F�al In Pest nn by_a %_ Y —_ DMa <br /> -- <br /> 1 CC Lodi 353 3521 Manteca 8:j•71CA 0 Tracy 835-5115 ,q <br /> etiltn all copies to:,E-nvironrnentel Health Permit/Service. 1601 E:-Hate ton Ave, P O. P,:x 2009, Stk., CA 95<.7 � yi <br /> n c[r aMC!,N7 DUE AMOUNT REMITTED K a 11 <br /> i R rz`✓En BY r DATE PERMt7...N_o. r <br /> :fiN'r0 rAS -------+-- t�•� -`. '7i _ <br /> �1 <br /> 4�r <br /> ti <br /> va <br />