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: x =Pot:EFT ION iov DER"..T 1 W' 5t7w :C-ObiN U,LA, HE-LTH DISTRICT `1 AS 2 ci 1501E lephone (209.4 66.6.81 (. PERMIT N0. p�B 0.7 / Telephone (209) x66.6701 v GATE ISSUEO yy�:�pp CERNIi EtPiR[S 1 YCA0. FROM DA7F ISSbcG 3?p (Cocplete In Triplicats) b Application if hereby ode to the San Joaquin Local Health District for a pernit to construct ano/dr Install the work herein •y Describe!. This application is ode In compliance with San Joaquin County rdlnance No. 519 fer sewsge or No. 1662 for well pump and theAdd Rules and RegyJa ton Of CN an oir q 1 RC1 bd f q t JobAddress� J� T S{,DdtvtS ��11 " Owner's ham F,i rens Phone W Contractor's Na, tense No. 7X Phone TYPE OF YELL/P1eP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ ° y�ya d PUMP INSTALLATION [] SYSTEM REPAIR l7 OTHER LI li' Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. __PROP. LINE _ W FORaIDAT2ON AGRICULTURE WELL OTME0. WELL PITS/SUMPS K INTENUED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECII!CATIOS BVI o` ❑Industrial ❑Open Bottom ❑Manteca Dia. of Well Evtavation r UDwestic/Prlwte ❑Gravel Pack Tracy Dia, of Well Casing V ❑^w1.iu ❑Other ❑tli to Type of Casing Irrigatton __Appro-. ❑Eastern Specifications Cathartic Protection Depth ❑ hDepth of Grout Seal r r ❑Gen,',ysical Type of Grout _ ❑Other Surfart Seal Installed by _ Repair York Done❑ Type of Pump M.P. State Work Done .ell Deswrwction❑ Well Disaster Sealing Material (top 50') Depth Filler Metarial (Below 50') TYPE OF SEPTIC YORK: NEW INSTALLATION LI REPAIR/ADDITION A (No septic tank or seepage pit permitted if public sewer Is available within 200 feet.) 4; In-callation will serve: R idence Comnerct si Ether � N. Number of living units: Number o/ bedrooms Lo' site tWater table depth 14 Character wf Soil to a depth of D feet: 7 SEPTIC TAME Type/Mfg �/!Z7• Capacity No. Compartments PKG. TREATMENT PType/Mfg :apacify Method of Otsposal LT. U o- SEWAGE SYSTEM Dist.nce to nearest: Well �r�Fowulatie operty Line HO DESTRUCTION Total length/size _ � LFACMI!W UNE (J Fo. t Length of lines -` TILTER BED ❑ Distance to nearest Neil foungation Property Line 3 € SEEPAGE PITS ❑ Depth Site 'lumoer —_ 1yy`..• SUMPS U Distance to newest: 'fell raundatlnn _ Property Line Iq: D15POSdL P0N05 v — yu' �v E hertby certify that i Mve prepared this apDitcaVOn and that the work will be don in accordance with San Joaquin County Ordinal state lawn. and rules and regulations of the San Joaquin Local ilea 0th District. None Orrtr ar Iftensed agent's fiqn+cure certifies the following: "t certify that to the perforniance of the work for which this r permit ft SSfuM. i Shall not MD OF any person in Guth manner as to DBcome Su�]!ct t0 wdrhman%Compensation laws n1 California." - Ennt-actor's hiring or sub-contraCting signature Certifies the f011OW!ng: "I certify that 1n the performance Of the work 'or which this plrsl[ IS (SSYld. 1 Shall ny pe'Sons subject to workman's CMpsnsation laws Of California." The apill 1 or el eq red O'sDect ns Complete dr Ing on reverse side. g Signed A Tltie: (/}(,O[—k�11- Onte: G7/ k �rrYYrOi�yyFAglMEr USE 011L+ CStk x66-6761 Application Accepted ty _=J�L"J �—�^rear Fdditlonal Comments: / ___ ____. __1 Lodi 059-052 nv _ Manteca 627-7104 Pit or Grout Inspection b __ Date U d : Final Inspection by _ty(iff 7 .. .J _._pat! _ (J Tracy 875.6J65 h Applicant . Return ail Copies to: trvir,n W.tal He rvlces l6L E. Hazelton Ave., P.O. Boy 2009• Stk., CA 95201 y gvlwu•,- DUE 1,nU-P' REY17'EO 01 EI:ED By DATE RERMti I rtE 1 BASE �_—__�-- _ --1 IVO I a �3 $3-003 10/1:2 SOC, Ee 13.Z- l:-Ze