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h I ICATION I Illi VIAIIVlll SAN JOA(ItllN LOCAL I ILALTtf DISTRICT ltrrll f: IIATiL'iON AVISIOCKTON. CA Ihtlhilhlkntu f:KIyI 466—ti7ilI )9'r7{Lt f I�IIIIIMJr.;itxi'initlJ 1,,Y,LAii t1.lpM'}Df1TU FOQu90,• .•,:: � NLTN lj4 Sg1GtA•'• EG:rslnptutn IR 111j+Irt:utiA }0A��ti 1 PYA'.`1f.A1-T , Applketion ishrraby mads to rho San.n+cluin La'+I Health Gislricl IrSr a{wrmrt io ennslrNct anRl af:Rntflllc]rfyte8u�jl�icrllied, Tfra appliealipn u made in cdmPhdrice with S••n Ju.r4uin Cumity Ordinance No,IAS ler sowahpr tar N4. 11112 to)wrgl nr p and 1h 1 +c's 3�'aqulatiuns of the San-'oaqu,n Local Health 01;irii 1. Job Address ABX 90' north of Dmjqlw & 20' ErLst:o£ P,.a�City_Stccktm ;at SiI _. Nom+ Pill — Owner's MOwner's Name — A%1Ck Zr11 Cbl m-- AdAros! 17155 . E Sa= nenbO -_ Phan, (916) 921-1100 Conhsclou 1 Rrn Address 1386 E`EkV=C St.r MAtrland Lfeense Nei `�7 Fill gl5) 552 3541 r TYPE OF WELL/PUMP: NEW WELL I'1 WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION Li SYSTEM REPAIR Cl OTHER 0 DISTAUCE 1'0 NEAREST: SEPTIC TANK — SEWER LINES 50' DISPOSAL FLO. WA PROP.LINE FOUNDATION_ AGHfCULTU_RE WELL _ OTHER WELL PITS/SUMPS INTFNDED USE TYPE OF WELL PROBLEM AREA - CONSTPiCTiON SPECIFICATIONS 173 Industrial ID Open Bottom I 1 Manteca Dia.of Well Excavation _ 1R" Du,of Weg Ctrs:nhl "' ❑Domestic/Private IN Gravel Pack I'I Tracy Type of Casin(j PX-- Specification@ 19 Public I]Other M Delta Depth of Grout Seal Type of Grain}F tE I I lrrigalion —_Apprnrr.E}ePth I 1 E+stnrn Su+faco Seal Insfil lvd by I Repair Work Done 1.1 Type of Pump .— H.P. _ __ — State Work Done_ Well Destruction G Well Diameter Yn" Seating Material(top 301 (16 S Wd rvxhmt+51k bmimltn Depth f5Filler Material(Below 90'i /3{L'} #293DYISpy Fk]D1 TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNo seplic system permim i It public sawn ie availabia within 200 fri Installation will sail Residence-- Commercial— Ulher _ . Number.of living units: Number of bedrooms--._—— r Character of soil to a depth of 3 feet Water table dal SEPTIC 7A-NK Cl Type/kilg _— _ Capacity NO,Ca.npsrtmena PKG.TREATMENT PLT.n M,:Thod of DF.posal Distance to nearest: Wall Foundation__ _ Property Line LEACHING UNE Ia No,6 Le.ig!h of lines _— .—._ _ _—w —_ _ Total rength/siza FILTER BED CI Distance to nearest: Well -___._ mandation Pro►arty Line SEEPAGE PITS I I Depth --Sire---_..----. _. _ __ Number SUMPS i I Distance to nearest: Wial .- .._. foundduan___—.�_Property Line DISPOSAL PONOS V., I hereby certify that I have prepared this application and That the work wdl t,a lone in dccardance with San Joaquin county ordinance.,stale laws.-and Riles and regulations of thu San Joaquin Local Hal DiolriCt. Home Invrrrt+or licarl agent's signalute cartifies the foRuwutg:"I certify that in the porforrnance at r;m work for which this permit is issued.1 @hall not - amplil any perecn in such manner as to became subluct to wurkmdn's compinsauon laws of California."Contractor's hiring at suDronutictin9 signator} certifies the following:"I certify that in the pertormance of the work for which this permit is issued,I shall employ poisons s;bjec!to w kmaa'a comperts>a tL tiaee laws of California." SAN JOAQUIN LOCAL HEALTH DISTRICT' The applicant all It for r n Complyle drawing on r_oacs side. ENVIROIVMENiAL H LlIVISION ' Signed _ Title: "s3^esiciertt V1.- FOR DEPARTMENT USE ONLY Ap tion Accepted by •� Daoe ,l_�_Area Pit or Graut.lnspoction by — Data—_ Final Inspection 6y_ Date i Additional ramments: -- 1 Cl Stk 461;-6781 ❑Lod+ 369.3621 L7 Mantoca 823 1163 1 I Tracy 835.6385 Applicant-Hewrn all capias to:Enviroomantal Heulth Permit/Surocus 11501 E, Hazelton Ave,P.D.Box 2003,Stk.,CA 35201 i .. - FEE AMOUNT CLUE AMOUNT HLMITTED K a Hicl iVED,Y DATC PERMIT HO. - - - i INFO 1. . .EH t3-24 Ift h.M , o�+% ti i I `�!—:+l5 RH 14]eza i r' -