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PERMIT E:XPIRFS 1 YEAR FHOM ,AiL i:i:.til. il t - iCUltl[,fl(!1 E: lrl TIII)It(;J(F:F Appkc.ilam.�ho• by to il,r' Sir„ .lomi un to::al Hnalth Dim(ict for a permil to construct and.of install the work here,n descnned TMs ',Cat+en I. a 11-01•If,r r+nq i..w a ri0'i .rr+rr% Ot,rr,ante No !A9 lot spwdyle or No ltth2 1.1,wail i,t)-n and ib,+ ilea and +••tlulatrof,5 of The 1 Joaquin l•- .ri Ireauh ih•.rr n-r ��/�..r��L c� /1 G Joh Arld,ry ',�k '_Girt S,aa- („nner'c '!.noir j`, .f- 1 d+e55 ` Phone ^a Cn•It.lk!l,r `._ 1�. Sflitlprrss _ _ _ .- .Licens^ Ifo. 7 TYPE OF 1"DELI PUMP NEW WELL . . WELL REFLACEMENT 1 DESTRUCTION i PUMP INSTALLATION SYSTEM REPAIR OTHER i i DISTANCE TO NEARE;T SFPTIC TANK —_ _ SEWER LINES ._-_ __—. DISPOSAL FLD. PROP LINE FOUNDATION AGRICULTURE_WELL — OThER WELL.-_ PITSfSUMPS II':TFNDED USE TYPE OF WELL PRO13LEMAREA CONSTRUCTION SPECIFICATIONS_ InduStndl Open flcitom I : Manteca Dia. of We11 Excavation ___ —_—__ Ola. of Well Casinq — Domest,crPnvate Gravel Pack i I Tracy Type of Casing Specifreatwns r{� Puhhr ' Other i ' Delia Depth of Grout Seal _._ _—. Type of Grout hnydlum Apl+rr++ Drltlh I Easlurn Sul}are Seal InStdlled by Repair Wofl. Dong : ' Typo of Pimp _ _ H P __ _ _ _ State Work Done Wet Desirurt,nn Well D,.I.nel+•f _ Scaling Material flup SO E Depth Filler Matpndl (Below 50'I TYPL(If SE PT WORK N(W INSTAL I AT ION I ' 81-P.MfADDITiONX DtSTRIdC110N INo Septic system permuted it public iocw�r is available within 200 tact,) Installation will servo- Residt,nre Commercial Other Number of living units: .. ._ Number of bedrooms Ct,ardcns of sod to a depth of 3 t.t,:t _—_— _—. _ _ --_ — _— Water table depth SEPTIC TANK t : Type'Mfg — ___ - _ — Capacity.- _—__. _ _ No. Compartments PKG TREATMENT PLT I I Method of Disposal Distance to nearest: Well Foundation —_ Property Line _. LEACHING LINE No. R Length o1 linesT uWI IenyTlhlsize-- I TER BED I Distance to nearest: We Foundation Property Line SEEPAGE PITS I ! Ilppth t Size _ -'— _ Number SUMPS I Drsldnce"'110 ncareSt: Well — Fu onda nn — Property line DISPOSAL PONDS /� �'+� Wit[ r t L �� x .t 1 hereby candy that I nave propafnd this application and that the work will be done in accurtldnr a with San Joaquin county ordmences, stair_ <�ws, and rules anrd reqularions of The San Joaquin Locat Health District. Home owner or licensed apent's signature cortdies the fol!owlnw "I certity that in the pertorma,rce of the work for which this permit Is issued, shall not employ any pefson in such manner as to hocmmn suhlect to workman's compensation laws of CalJorma"Contractor's hiring or sub-contracting �gnatura ceruhos the followmg:"I cattily that in the performance of the work for which this permit is Issued,I Shall employ persons subject to workman's compensa- tion laws of California.” The apphc 1 call for alt - clions mpleta drawing on reverse side, Signed x \« f\ — —�Y2f� Ete: r �—,� Data: �lr ; I,y FOR DEPARTMENT USE ONLY J APPI'cgti�n Accepted by vl � �1�� Date_ Area 1� _ _J/ --Pf1 gF Grdut�ns Cbby on by Final Inspection b +� Dat. ",4 �+ _ / y��Additipnel Comments: f'f//� � j.j�i¢,C� .Y yV &"41L1?a!•v� Stk 466 6781 I'. Lodi 369 3621 ❑ Manteca 823.7104 L7 Tracy 835-6385' +Y^t Applicant - Raturn all rcpio,to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Slk., CA 95201 �r',ti� •� J ✓.1orrrr FEE INFO AMOUNT DUE AMOUNT REMFTTED CASH RBY `D'ATE PERMIT N0. f��/✓ EH 11 74 Lary , , �G7 i`,GF l.;o 7/ I4/ECEIVED� /+� FH 11ht