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Eff=2 . - »I'I'I ICAI if IN 1 4)It I'hllnit I SAN JOA( UIN I OCAL IMAL'M LIISTRICI •- iwn I. I!An: ION AVI-., SKICKrON, CA 151R10 1 tdntrttollu f:SIJ) dfid-li A>L H�`L p V151Q l I'WlIf1'17 IL 7tF'1NCl3 1 Yl;,AH;F1ipMrl>AT#i MIME[) 11,1OC. l-i . . :,. IGr,rt�piulu;In 1 ti�iiir utulAN p� NN��A��►�� Application it hmeby made to the San Joaquin•Lgral Huallh Oiarrcl fcr d 1111lo'cnn�truci ant/attlir'l�ll�ut� in des;ribed.Itis appliyation is made in compitrnce with:;dn Jadgwn Cuupry Urdoiencu Nu.6x19 lur wuwatpt w Nu.*l8b2 tut well/pump and t1wIffulut.and Fiegulaiium of the Sart Jouqumn Local Hdallh Distort. : 150' Sbuth Of ).a9 & 20' 1��Of is SLOC)IM N Job Address _ �� f _ City_ Lai Sita � PM_ Owner's Name Rcoj�!L=.AWi�k'!rill Q11 Cb. Address 1765 f}LY1199M Sa'Xd-R1 ttn Phona (916) 921-1100 Contracior 1v tPt1T _ Address 1NIS E- EtarrPX&� �"��,License NOM-7 —P'lon 6) 662-4541 TYPE OF WELL/PUMP: NEW WELL I1 WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION 0 SYSTEM REPAIR Cl OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 50' DISPOSAL FLO. PROP.LINE FOUNDATION_ WA_ AGRICULTURE WELL � OTHER WELL t= PITSISUMPS H- INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS 0 Industrial U Open Bottom 1.1 Mameca Dia.of Wall Excavation _ 1R" Dia.of Well Casing• " ' 0 DoeestielPrivata DO Gravel Pack 1']Tracy Type of Call ptx� Speeiticatlana 19 Public I'l Other DO Della Depth of Grout Seal '_ Type of Gral to ! I Inigatian ___Approx.Depth I I Eastern SurldCu Seal Inst ii ied by�. De=Ia - - - Repair War%bone 0 Tvpe of Pull _-- H.P. _ — State Work Done_ Wall Destruction Cl Well Diameter _10" Sealing Material ltop SD'I (30%) lbBt 0?rrxtl- + 5116 1rrtlrxtilr Depth Fl Filler Mareral IBetow£101 (30_.} #3 bab=W rtPa'yT TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No seplic system permitted if public saver M . available within 200 feet.l Installation will serve: Residence Commercial__ Otlter liumtter a1 living units: Number of bedroa.ns Charactar of soil to a depth of 3 feet: _— Water table depth SEPTIC TANK I:1 TypBlMfg —_ Capacity No.Comparunents '- Pi TREATMENT PLT.rl Method of Disposal Distance to nearest: Weil „-_ Foundation Propany Line LEACHING LINE I:1 No.i3 Length of lines____._ __ Total fengthlsiro FILTER BED. 1-1 Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS y I I Depth -_ -Sire.____..._. '' -». _� Number SUMPS i I Distance I!)nearest: Well Foundahon_-_..__ Property Line DISPOSAL PONDS _ I I I hereby ca,tify that I have prepared this application and titan the work will Lu tl.,ne in accordance with San?oaquln county ardinancas,state laws,and rules and regulations of the San Joaquin Loral Health Di9utct. Horne owner or ficensed agent's aitlnaturo certifies the followrnp:"f cbn.ly that en the performance of the wi for which this permit is Issued,10.40 not employ,any person in such manner as to become subject tr`workman's compansdtiurt laws of California."Conuector's hiring ot sub-contracting Iligna:ovii certifies the following:'7 certify that in the performanco of the work for which this parr.;t is issued,I shall employ parsons aub' tion lawa of California." SAN JOAQUIN LOCA The applicant mu I fa E s.Complete drawing on reverse side. ENVIRONMENTAL HEALTH DIVISION President SPEC41 PERMIT89 Signed — Title: Ala: -- - - - FOR DEPARTMENT'USE ONLY AjsP=orlon Accepted by 1[�r,.-,�_.. _ Ddte T_t� Area- --- ---- Pit or Grout inspection by Date _- Findt Inspuctiun by Data _ Additional Comments: --- 0 Sik 466.6781 0 Lodi 3693621 1 Manteca B23 1104 1.1 Tracy 835 6385 pplir it-Return all copies to: Environmental Health PermalServicus 16:01 F, Haralton Ave.,P.O.Box 2009,Stk„CA 95201 _ - FEE AMOUNT DUE AMOUNT RLMITtLDS.Ayln I HLCLIVED BY DATE PERMIT-NO. INFO �--- ---- SteI •FH 11-7t Ir1EV.r,xer �;� C:� 1�7 -_ /h Lop, IN 1: _ ""'