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<br /> :11MIT EXPIHGS 1 YEAH I-110M DATE ISSUED l ��11n(HtVISION
<br /> ,.. ..• ..",' LCultlplille iR•lriplic�ttrl' :1OAQ�It4'�1OALM ALS
<br /> Applirarron is hereby irkadu to the Sart-frl qu"I Local Ife dit,Drstlrcr k,r•pe lln$ru cnnshuct f ITik"� k� l 'ad.This+pt techlion is
<br /> made in compliance with Sen Juaqum[uuuty U;d.narr�u,Nu.1;49 11:eA•.ge ui illItk,2 Fur wail/ r r grid rad Ilagulalions of the San Joaquin
<br /> Local Hoarrh Distract-
<br /> Job Address oximdt�?Y.. 20r est bra . aglas fmn Pmcific �;,y 5l.ocdd>rxt Lot Site WA
<br /> —�.__ _ .-- — _ PM
<br /> Ownar's Name—RIII--AI 9Cklon3 OU.�b,__ Add,uss 1765 CYtall+e,90 Way, Sacxa"I (916) 921»1100
<br /> -• Phone
<br /> Contractor Fern Geo-1}tgjh ,g Addiess.i386 E. B3ffnCr St•, 1tbodland License No. 513657 Phone(916) 662-4541
<br /> TYPE OF WELI "'IMP: NEW WELL 60 WELL REPLACEMENT fl DESTRUCTION L7
<br /> _ - - PUMP INSTALLATION Ll SYSTEM REPAIR 0 OTHER N 1 12133.4k.11
<br /> DISTANC' -I NEAREST: SEPTIC TANK _N/ASEWER LINES �75' DISPOSAL FLD, N A PROP,LINE 221
<br /> ' r
<br /> FOUNDATION_.104L___AGRICULTURE WELL =NIL= OTHER WELL„100-1— PIT5ISUMPS .}S([A '
<br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO_INSTRUCTION_SPECIFICATIONS
<br /> ❑Industrial Cf Open eattorn I 1 Mantuca Dia.of Wall EACd VatiOn-- 1f1 •,. Dia,of Well Casing 4"
<br /> f]Domastic/Private Ile Gravel Pack I 1 Tracy Type of Cat,ing r`W Specifications
<br /> 11"1 Public 11 Other 00 Della Daplh of Grout Saal 301 w
<br /> Typo of Grout 1�iout�nHl.,'1F
<br /> I I irt.giLlion �!Approx, Depth I I Eastern Su,facu Sual Insidttad by��Si3
<br /> Repair Work Dona 11 Type of PernA __ H.P. _. State Work Done"
<br /> Well Destruction Cl Well Diameter Y,.1, rr Sealing Material itopvl W TImt cawnt +5%bl�lUmite _
<br /> Depth r>tir Filler Mdlar;al JawowXi 0' 63 linct'it hand
<br /> TYPr:OF SEPTIC WORK: NEW INSTALLATION I 1 REPAtR/AtiOITIDN I l DESTAIICTION I I INo septic system Permitted if pu:&-vw-ar
<br /> available within 200 fill
<br /> Installation will servo: Rusidenca Commercial
<br /> } Number a1 Living units: Number of badroorns „_,
<br /> s
<br /> Character o1 soil to a depth at 3 feat: table depth
<br /> SEPTIC TANK L1 Type/Mfg _ _--_ Capauly-- No.Compartments
<br /> [ PKG.TREATMENT PLT.F-1 Method of Disposal
<br /> Distance to nearest: Well-_•_____ Foundation _.- Property Line -
<br /> LEACHING LINE LI No.&Length of lines __ __- -__-_ Total longth/site
<br /> FILTER BED 1:1 Distance to rurarost: Well Foundatrnn Property Line
<br /> SEEPAGE PITS 1 I Du th
<br /> P -__- ._5etn..._ . . . .,.__-.....__. . . Number
<br /> SUMPS C] Distance to nearest: Wit-. ._. -,, Ferllldan011 _ -•_•_� Property Line
<br /> DISPOSAL PONDS I I
<br /> hereby certify that 1 have prepared this application and that lhtr wp,k will bu duuu cal dWlirdanee with San Joaquin county Ordinances,state laws,And
<br /> rules and regulations of the San Joaquin Local Health Oisirrr•.t.
<br /> Horne towner or licensed agent's signature certifies the lallnwrng:"f cartery that in Ihu puriormanca of the work for which this permit is issued,I shall not
<br /> employ any person in such manner es to become subluct to wurkmari s compunsabun laws at CulelOrnw,"Contractor's hiring or sub•cantracting knature
<br /> certifies the follov Ing:'•I certify that in the performance of tllu work fur wfuch thra permit es,ssued,1 shall employ persons sub act to workman's c
<br /> Hort laws of California." SAN)OAQLIIN LOCAL HEALTH DISTRIC 7rasa•
<br /> The applicant nil cal r aI i do ornpletu drawing un revurso lido. ENVIRONMENTAL HEALTH DIVISION
<br /> Signed rine: PresiderttSPECIAkPERM,%/w
<br /> ate:
<br /> FOR DEPARTMENT USE ONLY
<br /> Appii Accepted by �� �- r ..•..----- ._.. 113,110e-:149!9— Ana
<br /> Pit or Grout Inspoction by - Dole_•_,__ Final Inspection by Date
<br /> Additional Contril ,
<br /> 0 Stk 456-6781 0 Lodi 363.3621 ❑Manteca x23.7104 I I Tracy 835.6385
<br /> Applicant• Return ell copies to:Environmental Health PermitlServrcns 1661 E.Hatultun Avu.,P.O. Box 2009, Slk.,CA 95.201
<br /> FEE AMOUNT Ill AMOUNr Fifi flb ���� Ht CLIVED BY DATL PERMR'ND.
<br /> INFO
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<br /> IN 132411111 It Ill
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