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-PP,ICAT:0% FC- E_•, 1'61 E. •.a EL' . .:.L. rERM,. DATE ISSUED PEPMI`Err)kES 1 YEAR FROM 1a'E °SSPE, ttJ(Complete in Triplica-e) ADDIiCattor, is hireby -al.. ';, c ian JOaquir Local Health District for a per^it to construct and for install the work herein des,.ribed. This a:pin a;+ a4n .n compliance wth San Joaquin Coun•y Ordinance No. 449 for sewage or No. 1862 for well/Dump and the Piles and Wequlat' t'e San Joicy+n Local Health DI;trict. Job jd0•ess_!0&2- ,4-/�• pin Subdivision r.)rner'• SaTe !1-tl/ . Address Contractor's Contractor's Name /.' Phone - 47 �f UUU 1/Jfin License No, q .1$ Phone b�a77-?- :YPE OF akLL,TUMP W(`RY: %Et: WELL WELL REPLACEMENT L DESTRUCTION� y 4• „TAE;ATipN SYSTEM REPAIR lJ OTHER DISTANCE TO NEAREST: SEr':C *:v• -��f SEWER LiNES DISPOSAL FLO. PROP. LINE 1 I FOJtiDAT;O•. _ AGRICULTURE WELL12L_ OTHER WELL PiTS/SUMPS INTENDED USE - Ti"E OF WELL PROBLEM AREA CONS'RUCI M SPECIFICATIONS I Industrial �-„ fl I 1- -J �! a n Bottom Manteca Dia, of Well Excavation JJ Tbmestie/Private •nivel rack l_J Tracy Dia, of Well Casing —$� I1 PublicJ Other U DeltayDe G � Irrigation --_- Approx. Eastern Spec of Casing S ffC (o Depth Spec+f of Grout Seal []Cathodic Protection Depth of Grout Seal (_I Geophysical --- Type Of Grout CJ Other Surface Seal installed byIZ400 �Q Repair Work pone [) Type of r,,•,!, �V �M.P. @L - State Work Done __—^_ —_ •7 Well Destruction ❑ well aiareter Sealirg Material—(top 50') i - Depth -, Filler Material (Dein SO'; - - R_ TYPE Of SEPTIC WORK: NEW R+�T c C } LL:.TiD'+ C ' ralR/.4DOITiON U (Ito sentfc tank or seepage pit permitted if public sewtr is 1 available within 200 feet.) ( Installation will serve: c'r�:9encr _ Commercial - Other - f Number of living units: _ _ Number of bedrooms _ Lot size Character of soil to a dept- of 7 feet: Water table depth SEPTIC TANK l Type'Mfg Capacity No. Compartments - PKG. ToEATMENT PLT. U Type,1-11 - Capacity Method of Disposal SEWAGE SYSTEMa -- - -- v Distance to nearest: Well Foundation Property Line _DESTRUCTION -" LEACHING LiNE a 140. % :ength of lines v Total length/size FILTER BED 1 Ois'-an_r to nearest: Well Foundation Property Line - SEEPAGI Ti TS - -- 'i•r•' -- Site Nui her SUMPS ri.•arest: Well Foundation Property line OiSPOSAI PONDS -.--_ ------- ------- I here+, cortif, that 1 h.i+• -• i this application and that thn work will he done in accordance with San Joaquin cnunty ordinances. state kiwi. afd rul, .•d rolulations of the San Joaquin Local Health District. Homeowner nr Ivan crud aa...�r i^i•yr0 Cer'•Ifies the follnwin0: "I certify that in the performanr•e of the wnrk for which this t yermit is 'sS,u J, i Jiall I•,, n•., pei�on in such manner as to become sub.:act to workman%compensation law-. of Cafifnrnin." Contractor's hirinq or suh.c,),tri-•!.ni signature certifies the follnwinq: 111 certify that in the performance of the work for which (+ this :ler-if is 'ic5ued, 1 "J1' •1•, rersors Subject to workman's compensation laws Of California." The aprlicant uc; rnII I' .•.•I; :d inspection,. Complete drawing on reverse side. silnrd Title: tGCC R_GS.-. --- Date: 'c 7w[V USE ONLY Area CLL- 1_2 St, 466-6781 I ><Lodf 369-3611 Tit cr I� � --- Date �j `J Manteca 823-7104 cinai c. /C1{:� li,e lr A� Cl Tracy R35-8385 =L[licant - `tor•' i' y' +-"rtj• ",•nith ^ermi!/services, 16 I E. •azel+.on Ave., P.O. Bnr 2009• Stk., C' 95701 pECC16'EC pATf - crvy