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APDLILAtiON FOR PER•'!-,' Ste'• ZGAOL;h LOCAL HE -LTH , ;S'QICT 1601 E. HAZELTON AYE, %1)(0 0%. CA Telephone (209) 866-67'91 PERMIT EYDIRES I "EAR FP04 DATE ISSUED (Complete in Tr+plicate) PERMIT 140. O�_73Z DATE ISSUED � -13 -'eh Application is hereby made to the San Joaquin local Health District for a Dermit to construct ane!or install the work herein described. This application is made in :ompeiance with San Joaquin County ordinance No. $ag for sewage or No. 1862 for well/pump and the Rules Ord Regulations of the San Joaquin Local Health District. Job Address I-V?j51 Al /L eq, Subdivision Name Owner's home Address Contractor's Name ��license No. 3 1 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTiCN PUMP INSTALLATION SYSTEM REPAIR l.! OTHER U DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES CISPOSAL FLD. PROP, LiNE FOUNDATION AGRICULTURE WELL OTHER WELL PiTS/StMPS INTENDED USE TY^E OF WELL PROBLEM AREA CONSTRUCTi^N SPECIFiCATi(M I] Industrial L.1 Open Bottom Manteca Dia, of Well Excavation _ V Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing s_ iD Public [j Other ❑ Deite Ty" of Casino _ V Irrigation Approx.iJ Eas'ern Specifications [ Cathodic Protection Depth LjG•wphystcal Depth of Grnut Seel Type of Grout L—I Other Surface Seal installed by _ Repair Work Done ❑ Type of Pump M.P. State Work Dore ` Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') _ TYPE OF SEPTIC WOPy: NEW ;NSTAL,A'i0% PEPAIRl,DUITIO!+ 1_, ('in seGtir tank or �-eparre pit Pe-itted if public srwr it available within 1110 feet.) Installation will serve: Residence rl Commercial Other Number of living units: / Number of bedrooms V _ Lot site Character of soil to a depth of 3 feet: /%j Water table depth SEPTIC TAU Tipe/Mfq_ ; }i„C. _ - Capacity Co•Dartments PKG. TREATMENT PLT. [] Type/Mfg _ i� _^ Capacity Methnd of Disposal SEWAGE SYSTEM Q Distance to nearest: Well 6a?� _ Foundation __/rf,/". Property Line DESTR•1CTION —7 - _ LEACHING LINE �r No. A Lenqth of t•nes �l' Total lenotn/site FILTER BED ��Distance to nearest: Weli �[//- loundatinn _.Lt/,X—Proverty the SEEPAGE PITS Depth Site NumM•7_____ SLMPS Distance to nearest• welt - 'o1,^dat+or _ - _- Prnperty Itno DISPOSAL PONDS E I hereby certify trat i hJ ve pre;ar.•d t^t•. �. f11'at+nr and •h1' •hn •W, .01 to dn— in .1, .rr•uern w,th 4' .!nanuin County ordinances, state 1lws, and rules ar.d rerutaa 0^ of ire San 204•»in Local ,4.4;!n � •.tr,r•. H]me owner or licensed agent's signature tertih ns the- !nlinw,nry, 'T certify ttat 1• L.,• i.•rfnrnance of the wn•s fnr which this permit is issued, i shall not employ any rertn, •n su..h ranner as to teCn••'e Wt•!•• t to wi,r—ns. rrinr—%at,— lee•, of raltfn,a." �ont•aeto-'S hiring Or tub•Contraetini L+7natJ'! Certifrft ti` f',lo r•n�; "I C.rt fry ••,�♦ •n ire pnrrnr•a— nr r,he work fSr A%.:h •,hit perr'1C it ItSUf•d• I Shall f—piny Ceeson; S�rt`IPc' •^ wr r:-,yn'•, 'l'^•n•,at •r1^ law' of 'il•`r rn!a, The aPD11Ca'+tf t cell fo`r 111 /^r�puirM •n •,,,ar t ler �- i-; '..•" dr ,^,r -i nr r. frr•,w • •.!r, 6- 7-4.!Y _ soft ice Ion Ac,••tta•d cr � ' Q •' q+• .+ " �d�12i,.nJ• v•rnt: _. ._._._.�_�. _ � i. .3. .ill .:I'�Jnt - ♦.syr 1' r .. ter .. _. .. - _• .. �� G 713�4y S'i Lj L i W V' Z