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APPLICATION FOR PERi)�iT ✓✓ SA.N .IOAQUiN LOCA'I H'ALTH i,iSTRICT PERMIT N0. '93 -3 L3 1601 ETelephoneN(209) 466-6731- DATE CA ' DATE ISSUED � � Y'3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) lor l the rein Application ih�5eaeblicateonoisthe made inocomplianceLocal withlSan District Joaquin CountypermlOrdinance cNo. 549tfordsewagesorlNo. 1862rforewell/pump ' described. T PP and the Rules and Regulations of the San Joaquin Lo al Health District. t .� � d�ei�n Name Job Address Phone O Address -F g Owner's Name License No. Phone .� Contractor's Name 4 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [ DESTRUCTION e SY.ST.EM REPAIR OTHER PUMP INSTALLATION _ r f �� r` + PROP, LIKE ^� t 1 DISPOSAL FLD. .,.►-. ---� -" ""_"-.'.._, DISTANCE TO NEAREST: SEPTIC TANK ^�. SEWER LINES' -^*-- PITS/SUMPS ..SEPTIC TA*--- —�� OTHER WELL FOUNDATION _ AGRICULTURE WELL CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL PROBLEM AREA pia. of Well Excavation j� Industrial U Open Bottom ❑Manteca -- LJ Domestic/Private F7 Gravel Pack Tracy Dia, of Well Casing Public [j Other Delta Type of Casing Eastern,•�.`-.�..'_'.,'_'""-'�.. .- -� Irrigation Approx7 '[]" Specifications Cathodic Protection Depth Depth of Grout Seal D Geophysical Type of Grout L]Other Surface Seal Installed by Type of Pump H.P. State Work Done Repair Work Dane � Yp Well Destruction U Well Diameter Sealing Material (top 50') U P' Depth Filler Material (Below 50') -`� REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is TYPE OF SEPTIC WORK: NEW. INSTALLATION ❑ available within 200 feet.) Installation will serve:,_ Residence Commercial _ Other Number of -- - Lot si'ze7E 1 Number of living units: bedrooms I Water table depth Character of soil to a depth-of 3 feet;, No. Compartments ry-� Ca pati ty � ' SEPTIC TANK. Type/Mfg Method of Disposal PKG. TREATMENT PLT. Type/Mf9a Capacity '_ y J zf `JProperty Line Foundation SEWAGE SYSTEM Distance to4nearest: Well, t DESTRUCTION `+ }FF �--Total-length/size---^ LEACHING LINE No. & Length of klines Foundation PropertylLine FILTER BED Distance to near est: Well ' A Number SEEPAGE PITS Depth ` . Size r Foundation �. ��JtLine SUMPS Distance to nearest: `Well 9 1 - -L, DISPOSAL PONDS I hereby certify that I have prepared this application and ;that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies suchfmannnernas to becomeythat subjectntohe pe fo nc worrkman t compensation wlaws fof California." permit is issued, I shall not employ any p Co ractor's hiring or sub-contracting signature certifies the fallowing: "I certify that in the performance of the work for whit this it is iss d, i sh 1 employ persons s ect to workman's compensation laws of California." The lit must f r a 1 i ect' ns, omplete �awing n rever side., f{' Title: 1 � Date' �- Signed 10 a k t `_ p USE ONLY Stk 466-6781 Application Accepted by ti kLodi 369-3621 Additional Comments: # ❑Date Manteca 823-7104 � L�- SUmp pit or Grout Inspection / Tracy 835-6385 Final Inspection by Date / L r e a: Environ tal lth Permit/Ser jc es41601�E. Hateltoo Ave.;;P.O. Box 2009, Stk., CA Applicant - Return all co 95201 RECEIVED BY DATE FEE BASE AMOUNT DUE AMOUNT REMITTED RPERMIT NO.'' L4 INFO y�� -33 1 10/82 500 EH 13-24 REV. 10182 (� 14-26 �/�