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ya <br /> s a <br /> Y`il'f: <br /> I a-; • <br /> LOCI <br /> ?CR. PE.RriIT f!D• 43 :`si: <br />` Teievhone 1?naj -EF r.ei <br /> ~ DATE ISSUED''�,� <br /> pEP.viT E+PIRES 1 YEAR FROM 047E 15SUE0 <br /> -- tcc)mplete in Triplicate) <br /> i;pl,cation is hereby 'lade to the San Joaquin Local Healte District for a periit to construct and!or install the work'hereln <br /> GnScr,bed. This application is made in comaliance w`th San Joaquin County Ordinance No. 549 for sewage or N0. 1862 for well/Dump .1 <br /> n❑ ;he Rules and Requ ations of the an 30anuin local ealth Distr,ct, ` <br /> 1W A Sbdi in Name <br /> Name <br /> hddress '.Phone <br /> icense No. N Phone <br /> Er,pLrnCtOr`s flame ye� ' <br /> irpL OF WELL/PUMPWORK: t!EW WELD _-WELL REP:ACE1+!ENT [� DESTRUCTION}�j <br /> n <br /> -�- _ - PUMP INSTALLATION C) SYSTEM FIEPAIR _IOTHER ❑i `ry <br /> ip <br /> PROP. LSNE �SEWER L1Nc5 DISPOSAL FLO. 1 ''.' s. <br /> %157A:%CE TO NEanGS7; SEPTIC DAN( <br /> � <br /> PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> 3, <br /> ~-iNT-�NOED USE TYPE OF WELL pROSLEM AREA CONSTRUCTION SPECIFICATIONS 4-4/ <br /> r pn Bottom Manteca- Dia.. of Well Excavation ' : <br /> indust ia} ❑ <br /> [geAbmeStSC/Privet? [] Dia, of Well Castng Gravel Pack [j Tracy � .. - "• 1 <br /> ;J Public ❑Other pelta Type of Casing ` <br /> V Irrigation Approx. [Stern Specifications ' <br /> (�cath,7dic -otcction depth Depth of Grout Seal . <br /> ' 1(moPhysitai Type of (.rout _.. <br /> 1J Other Surface Seal Installed by _ <br /> Repair Work Done ❑ lype of lump <br /> H.P, T - �State T1prk Done <br /> well Destruction ❑ Well Diameter �� (top 501) <br /> _ <br /> Depth � �Sealing Material Filler fiaterial (Below 50') r <br /> U: NEW INSTALLATION [I REPAIR/ADDITION (No septic t,�nk or seepage pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK ' <br /> 1l available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ other <br /> Number of living units: Number of bedrooms Lot size -- <br /> Character of soil to a depth of 3 feet: Water table depth t <br /> ;{ SEPTIC TANK Type/Mfg _• Capacity No. Compartments <br /> ` Pi(G. TREATMENT PLT. [J Type/Mfg Capacity Method of Disposal <br /> Foundation Property Line i <br /> SEWAGE SYST'„M Distance to nearest: Well <br /> DESTRUr,TION _ ❑ --- <br /> LEACHING LINE U No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: well Foundation Property Line <br /> Size Number <br /> SEEPAGE PITS Depth r <br /> Distance to nearest: Well foundation Property Line o <br /> SUMPS iJ — <br /> DISPOSAL PONDS ED ' <br />€' 1 hereby certify thrt l lave prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> H". owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work far which this <br /> permit is issued; I shall not employ any person in such manner as.to become subyect to workman§compensation laws of California." <br /> r,,nt.ractnr'c hiring or sub-cc,ntratting signature certifies the following: "E Certify that in the performance of the work for which <br /> ,ni; permit is issued* 1 shall emp y persons subject to workmen's clove mnsation laws of California.` .: <br /> Thr zui!icar�t_�/st call for al qui' inspections. Complete dr g on everSe !ide. ,` t <br /> Title: . Date: <br /> };•;ned s {fLi�l - <br /> O PARTMENT USE tfty © Stk 466-5781 <br /> "(/,C, <br /> icarion Accepted by Area <br /> Lodi 364-3621 <br /> 710 <br /> a,ldi'tinnat Carr,rents: , to L..i-Manteca 823-71E14 <br /> Pit Or Grrrut inApe[LiOn b <br /> 'noi 1nst,Pct Ion by _ -- <br /> Date � Tracy 535-6385 <br /> Rr!.,�n •,li rnpies M. E vrrormental Health Permit/51! vOces 1601 E.YHaxe2ton Ave., P.D. Boa 2009, Stk., LA 45201 <br /> -TEO RECE14E0 BY DATE PERMIT NO <br /> AHDUrT A M1i <br /> A:'M'1T our <br /> 1 <br />