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L A- PERMIT 'in. -OL3 S :A Telephone I2'01; 4E�- 7" DATE ISSUED -4 EIPIRES 1 YEAR P;r" (.Complete is tri Pllca.e; Application is hereby niade to the San Joaquin Local Health District =,r a tci—ot to construct and/or install the work herein or well/Pump described. This application.is made in co�,cliarice with San joaquir..�ounty ordinance No. 549 for sewage or No. 1862 and the Rules and Regulatior.s of the $a jacuiln Local Health Subdivision Name Job Address Z Address phone Owner's Name Phone Contractor's Name SIO License No. TYPE OF WELL/PUMP WORK: NE::' WELLI WEL: REPLACEMENT —1 DESTRj'�TiON f iJ PUMP INSTALLATION SYSTEM REPAIR 7- OTHER FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPCS�'� FOUNDATION AGRICULTURE WE;.1 OTPEaIl-LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA R�,C 'Er,rICATICrIS j industrial I Open Bottom F❑I Manteca Dia. or Well Fxcavacion Ll Domestic/Private Gravel Pack Tracy Dia. of Well Sas•nq Public U Other LJ Delta Type cf Casing Irrigation Approx. Easter-1 Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout Fl Other Snrfa:e Seal Installed by Repair Work Done E-j Type of Pump H,P. State Work Done r, Well Destruction UWell Diameter Sealing Material (top 60') Depth Fillcr I.aterial (Ge 10. 50') TYPE OF SEPTIC WORK: NEW INSTAL LAT:ON D R Zl-j. 17j"(;jj septic Lane or seepage pit permitd if pblic Sewer is 5 availablteewithinu200 feet.) Installation will serve: Residence _ Commercial Other Number of living units- Number of bedrooms Lot size 'datetable depth -t, Character of soil to a epth of 3 feet: ZVZ, 4�z, ;I�Type/Mfg Capacity No. Conpartments SEPTIC TANK Fri PKG. TREATMENT PLT. 10 Type/Mfg Capacity method of Disposal -SIN SEWAGE SYSTEM Founda-'on F-I Distance to nearest: WPI 1 Property Line ,k I DESTRUCTION ILLACHING LINE IJ No. & I.ength of lines Total length/size F1'-ER BED [—I Distance to nearest: Well Foundatill, Property Line Si GE PIT ze Pber SL, : 1 - SUMPS Distance to nearesi,: hell ound' —AX-111 Lion Pro P"ty Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the w- will be done in acco.-dance with San Joaquin CouAtY ordinances, state laws, and rules and regulation; of the San Joaquin Local Health District "I certify that in the V�rforma rice of the work for which this .0 agent's signature certifies the '010wing: I )npensation laws of California." Home owner or license hall not employ any person in such manner as to teco,.e subject to C(performance of the work for which ..permit is issued, I S certify th t in the per' Contractor's hiring or sub-con.,racting signature certifies the ftrlltl�`IC: ,I a this permit is ,sued, I Shall employ persons Subject to srjrkman s c,p,-,,satlo, laws of California." The applicant r. a, call for all ir-peti,,s. Com.plete drawing or, reverse side. Date: e; Signed X Titl —IcaoK-� F A'e. E"I L'! Area Stk 466-67,31 Application Accept-d by Lodi 3E9-31121 Comments:ditional Corents: I -ca 823-71C4 ant. Da.. G or Grout Inspection by'j��!." Final Inspect on by - -r-4:11- --- ; Tracy P,35-6385 ;50 �aze,,on P.O. Box 2001", Stk., CA ')5201 ,pplicart - Return aI C opleS to: y FEE I BATE (=a Sac 1�11a,