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:J AsIPLIGATION 1011 I FRIVIil ��•�� SAN JOACIVIN LOCAL Ii1:AL1'll DISTRICT tried E. IIAZELTON AV(-., S1r7CKTON, CA yc,(IZ1G� 1 uidlURrrRr 12091 41iti•6710 �[r�1•}1F4 4�`��1SION 1'811MIT-WIRES 1 YEAR l~FtdM DATE 18S�E�[��yy��1TlwLH1�`h�rt�� {rytlrnplola.lrll'r(filicnt�,I' SAS a��+pM ,4�,•��►�'�� Apo kation is Itelebv nada to the San Joaquln Local Hualtt,R'srrict lot a 4*(Mlt to conclruCl und/w install ih3)JFo arein ciateribed.This&ppkcatlon is Made in comphancii wish San Joaquin County Ordu,anco No tAlr fol suwatlu'or No, lo62'fue wudlpump and the flulvs and RepuUuons of the San Joaquin Local Health District. Job Address APP50 20 ' of- 189 & 20' Esti aP !�C-fiC C;ty Sbwkbn't Lot Sue - PM— I c-.vner's iV:mn T!w"�`1"'� m• — Address 1765C,aLt.tsr�._Vbv,=aTe to Phone (916) 921-1100 Contractor WsGerrt Address 1306 E. EINV r St. W=CLT-d License N0197--Phone(9;5) 662-4541 TYPE OF WELL/PUMP: NEW WELL ❑ yVELL REPLACEMENT la DESTRUCTION ❑ PUMP INSTALLATION U SYSTEM REPAIR tl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES 50' DISPOSAL FLD. N/A PROP, LINE N/A FOUNDATION _ ' AGRICULTURE WELL . ' . OTHER WELLS PITSISUMPS ILA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial 0 Open Bottom 1:)Manteca Dia.of Well Excavation 10" Dia.of Well Casing 41, 0 Domesti,-Mrivate 0 Gravel Pack Cl Trey Typo of Casing_ Specifications 1'1 Public 17 Other N Della Depth of Grout Soal 'an' - Type of GrouiaaL+ t9 I 1 Irrigalion _Approx.Depth I I Eastern Surface Saul Instaflod by no= Repair Work Done 0 Type of Pump H.P. State Work Done Wall Deal.ruction 0 Well Diameter In.. Sealing Material 4top 50'2 f(30' *1*--0-et f"+9A b'tmi—f'" Depth Filler Material 180bw 90') (nn'1 3' TYPE OF SEPTIC WORK: NEW INSTALLATION I I RLPAIR/ADDITION 1 1 DESTRUCTION i 1 (No septic system permitted If public sewer is available within 200 feat.) Installation will satva: Residence— Commercial.^._ 01114r -,.:.'.Number of living units; Numt ur of bedrooms- -_ edrooms_-_1 i-Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Typo/Mfg Capacity Na.Companntonta PX G.TICATMENT PLT.❑ Method of Disposaf *• ;aiswnce to nearest: Well Foundation Prapeny Line LEACHING LINE Cl No.5 Length rf lines Total fengih/site ! FILTER BEO;'" CI Distance to nearest: Woo _ Foundation Property Lina SEEPAGE PITS I I Depth Number SUMPS L 1 Distance to nearest: vVeii Foundalion_ Property Line DISPOSAL PONDS I-I 1 hereby certify[cwt t have prepared this application and that the work will be dune in accordance with San Joaquin county ordinances,state laws,arid " rules and regulations of the San Joaquin Local Health D3uict. Homo owner or licensed agent•&signature certifies the fallowing:"I canily that in the performance of-he work for which this permit Is issued,1 shall nc; employ any person in such manner as to become subject to workman's compensation lam of Californ.a."Contrac--jr's hiring or subcontracting signature certifiesthe following:"I certify::tat in the performance of the work for which this permit is issued,1 shall employ porsons subject ta,workman's compwuw liar[laws of California.' SAN JOAQUIN LOCAL HEALTH DISTRICT The applicant mast or a io .Complete drawing on reverse stile, ENVIRONMENTAL HEV11YVISION Sig Title: F3'�eE1i6ent FOR DEPARTMENT USE ONLY i Applies n Accepted by D,te 2- Area Pit or Grout Inspection by Dara Final Inspection by OAte Additional Comments: O Stk 165.6781 ❑Lodi 349.3621 ❑Manteca 8237104 Ll Tracy 835.6385 pplicant-Return all copies to: Environmental Health PerndtlServices 1601 E.Hatellon Ave., P.O.Box 2009,SM.,CA 95201 FEE AMOUNT DUE AMOUNT RLMITTED RECEIVED 6Y DATE PERMIT'NO. - INFO ��•• k IR 13-241 REV.l re 51 ~�. C!, .•'C CN 14.20 THE, FURCUMION OF DOaMENT � �E IMpRCM SUE TO '1 C )jTj0jT OF el- C GS