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h� APPLICATION,F0.11i.P . �-----' SAN Ji]AnUIN LQl9!L*.. Ml' 1601 E. HAZEIOIy A Telep"oe {20 4 PERMIT EXPIRE& 1`Y AR,F fQM (CofnP-isle inTrlpilca#eIr $r fication is — s Application is hereby made to the San Joaquin Local Health District for a paimit to construct arEdlor In �y�,�/�+ f)Joaquin made in compliance with San Joaquin County Ordinance No.649 for sewage pr Na 1862 for weEl!Pump attdtthtP►Y'!�'r = '� `r 4 Local Health District r s �4r, i fiv r i3t y"fI r� �s w •• '�$� j3z �5�` it ><a o P r Jt}�* 1 Gxtalf�► �. Or a M1 CITY sem' j+O :. , gyp& � �., £ i Job Address r R er,w ' Gi4 t;Y!r p r•. a �►ia:7��Sa►r►1�°Phone � Owner's Name heJ r" 'S A flddress 77 TP3ro� }s� "�'�.r� c'l J .M+' t{rAr ��d Qr �(gr Phone A. Contractor C7f u��ta� a-1'cf.-�,•f• Address� �/� 44 ST Llcetlse l o TYPE OF WELL/PUMP: NEW WELL K WELL REPLACEMENT © OEFfi•UCTIP l7 � 71 � r PUMP INSTALLATIONfi � SY15T♦=M EP, `h Grtikw is+ S E ,i '•,' i p S Q L; �.�0� �t�E�S' ��' to-�``,r DISTANCE TO NEAREST: SEPTIC TANK FOUNpATIaN ts"r(ae.+a ARIcuLTuRr_wEu "= oT�fR �- -: Tst�uMRS . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC9TI0[�iS I f r r t �• i8. of Well Casigg LI-Industrial ❑ Open Bottom 0 Manteca �t Dia of Well Excavation Q i Type of Casm$ $.i".�.� o fl�4.1 '+Speci icatigns t` 3 �3 Ltamas:l+e/ rival B Gravel Pack C1 Tracy rF} YP *a r a W�K� e t }af•Grout Seal'�Z Y� IT.YPa pfrou�� f'i Public n Other l 3 Delta D P h f rr .� .r ' I I Irrigation SGA'pprax. Depth I I Eastern Surface Seal Installed by Repair Work Done l� Type of Pump N on H.P. u o State 11/4/ork parte Material (top 50'l- t Well Destruction [j Well Diameter Sealing Ma R Depth - Filler Material(Below 60') TYPE OF SEPTIC WORK:' NEW'WSTALLATION I l 'REPAIR/ADDITION l I 'DESTRUCTION I I ANO septic system permitted i(public sewer is :. available#(thin 206 feet 1 E' t Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms s '' 1 f Water table depth Character of soil to a depth of 3 feet:_ Ca acit 'i`lo;.C9 irtment8 SEPTIC TANK ClType/MI$ fir` f PKG. TREATMENT PLT. Ll Method of DEspos$I Distance to nearest: Well Foundation 4 Property Line "t � y "T t Total len`thlsize k t LEACHING LINE EI No. & Length of lines - 9 Q FILTER BED L� Distance to nearest: Well Foundation Property erne ` t , SLEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: W 1 F..oundationProperty.i.ine DISPOSAL PONDS Ll I _ � I horeby certify that I have prepared this application and that tFia work will pe done in accordance with San Jodina aqurn county orltces,state laws, and rules and regulations of the San,'Joaquin Local Iiealih District. .i - x' E `"r' I a sig Home owner or licensed agent's'signature certifies the following: "I certify that in the performance of the Wairkjfor which this perrrut is issued 1 shall not employ any person in such manner as to became subject to workman's compensation laws of California"pnnmictor's hiring or`sub-cot►tractirig signature certifies the following: "I certify that in[he performance of the work for which this parmit is issued,i shall frmplpy persons slt6ject tp yyprknttin's camfiensa tion laws of California." r r f The applicant mus call for all required i spectio s. Complete drawing on reverse side. Signed V Title:ry r��o�,' t; f � -f Dille 11L� :-3 FOR_ DEPARTMENT USE ONLY Application Accepted by Date 1 Area 4';' D }1C it�a� ( Final Ins action b 1 Date P Y rout Inspection b D - _ ham. Pit or G pe 'I '01O r 1 Additional Comments: l„ F-1Sik 466-6781 O 1 i'�369-3621 U Manteca 823-7104 Cl racy 8311-6385 Applicant - Return all copies to:,Environmental Health Permit/Servicas 1601 E Hasalton Ave., P O,.Box 2AOBtStk CA 9520 y i FEE r c ' INFO ArvrOUNT DUE "AMOUNT REMITTED ' ` R@CEIVEp BY'b t PATE PERMIT NO._] „r 0 tt ," �3 - .. 1 i( 7_ . EH 1324INEV,I/A + - Di 1428