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x_ <br /> ,i(AT10S -0 AE;'.7 <br /> 1601 E. h;:EL iOn A&., ST&ITwa. CA PERMIT NO. �J�lPpt/J <br /> tri¢Doone 1209) 156.6701 DATE ISSUED3 <br /> r PEPMIT EIPIRCS 1 YEAR FROM DATE ISSUED <br /> (-omplete In Trip-.ate) <br /> Application is hereby rude to the San Joaquin Local Health District for a pe milt to construct and!Or install the work ne-ein <br /> described. This application is made in compliance with San Joaquin County Ordinance N0. 549 for sewage or No. 1862 for well/pump 1 <br /> end the Rules and Regulations of the San )oaouin Local Health District. 7LpS./LnA <br /> Job Ad4ress y Subdivision N /'--V�Y��` "���� <br /> Owner's Naee __Address .,1'?tm 47G V. -es�f-- � ( `� <br /> Contnetor's Wme XLicense No. -S ZC �Z G -_ Phore W <br /> ` 1 1 <br /> TYPE OF YELL/WMP YDNK: NEN WELL Ll WELL REPLACEMENT (] DESTRUCTION <br /> PUMP INSTALLATION [! SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES _ DIAPCSAL FLO. 'ROI. LINE _ CJS <br /> FOUNDATION AGRICULTURE WELL OTHER WLLL PIT;/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I�Industrial ❑Open Bottan Manteca Dia. of Well Excavation <br /> ❑OUmestit/Private ❑Gravid Pack rj Tracy Dia. of Well Casinglim ' <br /> lPub)tt U Otnt' ,J Delta Type of Casing _ <br /> Irrigation ApProx. []Fastem Spe;iftcations <br /> Cathodic Protection Depth <br /> Depth of Grout Seal _ <br /> l]Geophysical Type of Grout <br /> Other <br /> I_� Surface Seal Installed by _ <br /> Repa I Work Done❑ Type of Pump __-_ N.P. State Work Done <br /> well Destruction�j Well Diameter . Sealing Material (top 50') _ <br /> 6= Depth Filler Material (Be w 50') <br /> IYP: Of SEPTIC WORK: NEW INSTALLATION LI REPAIR/ ON NO septic tank or seepage pit permitted if public seller is <br /> available within 200 feet.) <br /> Installation will serve: Residence Ccmme ial Other <br /> Nee Number of living units: of Number of tedro s , Lot size <br /> Character of soft to a depth of 3 feet: _ rt— J Nater table depth <br /> SEPTIC TANK ❑ Type/Mfg __Capacity _— No. Compartments <br /> ` PKG. TREATMENT PLT. ❑ Type/Mfg _Capacity Method of Disposal <br /> _ :ENAGE SYSTEMDistance to nearest: Well Foundation ____ Property Line <br /> _ OESTRUCTICN ❑ <br /> ..EACHING LINE _ No. 8 Length of lines _ G Total 1enOth/s1z <br /> .ILTER BED Distance to nearest: Well r � o ndation �roperty Line <br /> me T—_— <br /> ,cEPPGE PITS L Depth J Size Number <br /> .JMPS LI Distance to nearest: Well f nr I/'foundation ti__^O_ am Property Line <br /> :SPOSAL PONDS `I <br /> ama <br /> nereby certify that I have prepared this application and si.:t the work will be done in accordance with San Joaquin county <br /> �c mantes, state laws, and rules and regulations of the San Joaquin focal Health District. <br /> •-Jr owner or licensed agent's :9nature certi'tes the following: "I certify tkxt in the performance of the work for which this <br /> l <br /> mit is issued, 1 shall not employ any person in such manner as to become subs ect to worknxnS compensation laws of California." <br /> 4 n;ractor's hiring or sub-contracting signature certifies the following: "I certify that in the perfornwnce of the work for which <br /> Ye �.�s permit is is! I shall employ per ns suoj ect to wOrkm n's conpensation laws of California." <br /> ^ a0plicant r ca 71 for all re spec tions. Complete drawing on reverse side. <br /> ,ted K .iwv' Title: Date: <br /> FO DEPARTMENT USE ON Stk 466-6781 <br /> Application Accepted by _ _Area _ ❑ <br /> Additional Comments: _ ' `ant 369-3627 <br /> Pit or Grout Inspection b __ Date L_J Manteca 823.7104 <br /> L Final Inspection by __ Date ❑ Tracy 835-6385 <br /> cant . aeturn all copie to. Envir nmental Health mermit!Services 1601'E. Ha elton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> JrE �BAMOOT SEOU` AMOUtR RCMI:TEO RECEIVED EIVEO CY DATE., �ERI;T.M'6 <br /> L ;f0 - <br /> 1/0 .29 <br /> IUTA2 S00 <br /> REV. IO/B2 <br /> L <br /> L <br />