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gliq lial lam All IrAllill I li I31•11AJi11 BAN .It►A11llIN Li l IWALT'll nISTRIGT �1S��1CT ll;U) F: 11Ar1--,L I'l.1N AVE„ s I nCKTON, CA L�,�A►��bVtst�� auluftltu+tu flu:�► nful Ii7llt Vlt4 LQ��'Htpl DA'mvNM��eA (Cum late I Y- •• P A Triplicate) Appliearian is hereby made to the San Joaquin Loc d.t10 ulh-'OisSrict for a permit 16 consrruci aad/ar install Still herein described.This application if' 'made in compliance w;14 San Juaquin CuunN Ordlnanca Nu.5491u(sil a No.1Hb2'tut wall/pump anti thu Hufas and 11egu1a[ions of the San Joaquin Local Health District. Job Address 43ZV2dMa1V 120' wa&t On fl'Lft1 pbl City u .�Cl>7[1 Lot Size N/A RM Owner's Name—�L_^_/1„Wirt�la.v1 CD7_ a.__ Address Eloy) S3CZatl Phonu (91fi) 921»7100 -- Canlraclor 7 a1 }��pddress 1386 E. Bamer St., 1r-ac3lcyx] License No, 52n7 (91fi) 6662-4541 TYPE OF WELL/PUMP: NEW WELL 00 WELL REPLACEMENT ❑ DESTRUCTION ❑ t�rlont PUMP INSTALLATION (7 SYSTEM REPAIR CI OTHER MxdbOr 4111 DISTANCE TO NEAREST: SEPTIC TANK —Xil SEWER LINES 75' ptSPDSAI FLO. PApP•LINE 200 FOUNDATION -.1-0O�t-.___ AGRICULTURE WELL OTHER WELL.-40pr 'PITS/SUfl INTENDED USE TYPE OF Will PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Indua!rial Lt Open Bottom 1.1 Manteca Dia.of Well Excavation r' Lis.of Well Casing qtr Cl Domest;c/Private . W Gravel Pack 0 Trar.y Type of Casing P1C Specifications I7 Public fa Other 0 Delta Depth of Grout Seal30' Type of GroutPkat CI3nMt 4545 - !I Irr-vtiylion - rAppror. Depth I I Eastern Surtacb Seal Instadud by 4 t8E?t( -F17CIjt1®Ci8 Rail Work Done 11 Type of Pump H.P. State Work Oone �- Wall Destruction ❑ Well Diameter _-lp” _ Searing Material Ill _ 0 ��oetrr3tt +5%b[31{xX1{tig Depth—65' Filler Material feelow T�l 0' #3 n=Tberity Said _ TYPE OF 5EPTiC WORK; NEW INSTALLATION I I .REPAIRtAbpITION I I DESTRIll Ill I I INo septic system paur iced if public sewer is Installation will sell`: Residence_ Commercial� Other available within 206 feet.) 1 Number of living units; Number of bedrooms Character of$oil to a depth of 3 font: Water table depth SEPTIC TANK 177 Type/Mfg _ Capacity No,Compartmema j Ill TREATMENT PLT,171 Method of Disposal Distance to nearest: Wen_ Foundation_ Property Line LEACHING LINE Ll No.R length of Eines Total IangthJsize FILTER BED fl Distance to nearest: Well ___.. Foundation _ Property Line SEEPAGE PITS �I I Depth — _Sun_....._-•„_._'- _ Number. SUMPS I I Distance to neall Wl -_ Foundation Preparty Line DISPOSAL PONDS 11 I hereby cal ly that I have prepared this application and that the wu[k ll be'toile in accordance with San Joaquin county ordinances,state fetus,and rules and reLrulations of the San Joaquin Local Health Di&tri,:r. Home Mel or licerosed agent's signature canities the lanowrng:"I cortdy That in the pedonnance of the work for which this permit is issuod,I stroll not employ Ill person in such manner as to become subieet to wofkman•s compensation Idws of California-"ConuactoPa hiring or sub-cantraeting tiignature Cartifios the following:'7 certify that in the performance of the work for which[his permit is issued 1 shad am to Von laws of California... SAN 10AQ��K�! 7M 14r�f�rRS&tuL'Copo►ynaa- applicant must for re [' amplate drawing on reverses twrRor MENTAL HEALTH DIVISION t Signed Title: Ptwidmit SPECIAL PERfMT/.9 Date: FOR DEPARTMENT USE ONLY Application Accepted by _ pare Arae_ Pit or Grout Inspection by Date _ Final Inspection by Date Additional Comments: ❑Still 466.6781 ❑ Lodi 369.3621 0 frlal 827 J10.1 1.1 Tracy 835 6385 �-!Applicant•Return all copies to:Environmental Health Purrnit/Survrces 1601 E. Harellon Ave„ P.O. Bax 2009,Sill CA 95201 FEE AMOUNT DUE AMOI'N�JHI,,EMITnTEO INFOEIiECeIVEO BY DATEp-�IREV.I n m — '