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APPLICATION F0; PCRMIt SA!, JOACL P• LOCAL HE+LTn DIS1R1Cr r''.a' i' 1501 E. lephonEl 0'•. dYL., 5,.,7,!u%, CL PERMIT N0. �3-I�_�� '• Telephone (20g) Ae6.-9n1 DATE ISSUED PERMIT EYPIRCS I YEAR FROM BATE 1_S IID _tt§ (Complete in Trlpliclte) '`;,7? APpl icatioc is hereby made to the San Joaquin Lncai Heal to District for a rer',it to Ronml.let and/or Install the work herein described. This application is nude in comoliance with San 'oap in County Ordinance Nn, SAO for kewago or No, 1962 for well/pump and the Rules, n RepJ�,lations of the San Joaquin Local emit trict, Y Job Ly Adorers S 7y W �./N NIL VIsion Nam • '!E Owner's Name MRS NOK I LIT iAddress aNy ^�-_ --��,___pine Contractor's Name weh CAR6Ue License No. Zy3 14 _ Phene ;t;-(rOry'y TYPE Of WEU/PUMP WORK: NEW WELL WELL REPLACEMENT (-I P[STRUCIION E] 3 PUMP INSTALLATION (] SYSTEM REPfdN Lj OtMLRW i :,h DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ 0151'USAL fLD. PROP, LINE i FOUNDATION _ AGRICULTURE bFIL O1NCR WELL — PITS/SUMPS 1 d. INTENDED USE TYPE OF WELL PROBLEM AREA [Ai TR_C117N_SMCIf[CATIONS (� Industrial U Open Bottom ❑Manteca via of Well Lxcavatton 0C/ I Lj Domestic/Private Gravel Pack Tracy Ola. of Well Casing I]Public CI Other [:)Del to -s -sfii Li Irrigationtype of Carlini _ 'DProx, Eastern yf, DepthSpecifications Cathod lc Protection D [=1 Geophysical Depth of Grout Seal17 --- +"-� Other Type pf Grout ql Surface Seal Installed by r Repair Work Done Tyne of Pump _M.P. State Work Done Well Destruction Well Diameter SeallnL Material (top 50') _ gt �* • Depth Filler Material (Below SO') " •v n yl. TYPE Of SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION No septic tank or seepage pit permitted if L'R1 ( public sewer Is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: _L Number of bedrooms ,� _ Lot Size J T3 a TQC —� Y ° Character of sail to a depth of 3 feet: Water table depth ---�Y N SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments +' PKG. TREATMENT PLT. Type/Mfg _ Capacity Method of Disposal i a '• SEWAGE SYSTFM DESTRUCT 1011 [] Distance to nearest: Well —_�_�-Foundation Prol.erty Line .'.',Y>-„, LEACHING LINE No. Length of liras _r- /Jr I. Total le'igth/size CJOI ' FILTER BED Distance to nearest. well 10u^ Foundation /Ole Property Line SEEPAGE PITS F-J Depth _ Size _ __— Number SUMPS LJ Distance to nearest Nell ^Foundation Pro)erty Line / DISPOSAL PONDS ❑ '� 1 hereby certify that I nave prepared this appi i.atlon and thut the work will be done in accordance with San Joaquin county e �y ordinances, state laws, and rules and regulation& Of the San Joaquin Local Health District. Home owner or licensed agent's signature efrt+f'es the following: "I certify that in the Performance.of the work for which this permit is issued, I shall not mnploy any per.nn in ouch manner as to become subiect to workmany compensation laws of California." Contractor's hiring or sub-contracting signu L,re certifies the followlny: "I certify that in the performance of the work for which this permit fa issued. I shall employ persons sobJect to workman's cor.,Pensa Con laws of California." The appliest call for all regbir/A/irsP..•,tlons. 1.011,le4 dra,virq on reverse side. - - Signed z �C�RL(/S}•L' R __- Y( Title. N(tt. Date: _Q� / APTMLN' SF Gl1 `�7 Application Accepted by _ ye. r Arm 6 [� SLk 466-6781 - Additional Cnmrenis: _ —_ -- _ -- [-j Lodi 369.3621 Pit or Grp:rt Inspection by _ Date U Manteca 823.7104 ?: Final Insoec tion by / f Tracy 835-6385 Applicant - Return all copies to: Lnv:ronoxrx. 'a.., l .c:1.y.o-vices 1601 E. Haze'ton Avp.,/ 1. Box 2005, Stk., CA 95201 I FEE I BASE I /.MUYT OVt I L LL ACC l' GV --- DATE PERMIT NO. INFO - I 4-15 a-'83 Z3- Ia)8_i r; Fh 13.2 REV. 12;::. 1�9/Rf1 10/82 500 IC-2n