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A (CATION F �vA OR PERMIT � Lo S,'y�Q SAN JOAQL)IN LOCAL HES -LTH RCAT 4IlD 1gg1 1601 E. HAZELTON AVE., 466-6781 Telephone 12091 N�CAQUIN Telep DATE ISSUED H�PL�HA�Iri 1��J15i0N 1 YEAR FROM C S PERMIT EXPIRES ate) p�$LI 'jALFAL This application is (Complete in Trip N11MRA� 'nerein described. or inst�I Regulations of the San Joaquin District for a Permit to construcWeildPump and the Rules and Re9attaCYleC� c�qg for sewage or No. 1862 for see made to the San Joaquin Local Health D he, Joaquin County Ordinance N° site t0ap PM�— Application is compliance with San made in comp Irxll Lot Size 333-1943 Local Health District. Edi r CA 95240 Phone (209) 40 N. Ma>� Street City 112 S. Mal St, - Job Address M & p Inv � $1LITCle Dr eS1ts Address eld 3-ve 5,,-4(,o3 n _Phone �Q k 2120 License No. � Owner's Name C,GG DESTRUCTION ❑ �V _CJ AddressOT WELL REPLACEMENT HERPROP LINE Contractor NEW WELL ❑ SYSTEM REPAIR ❑ FLD.� TYPE OF WELL/PUMP: TION ❑ DISPOSAL PITSISUMPS PUMP INSTALLA SEWER LINES OTHER WELL�� SEPTIC TANK —� AGRICULTURE WELL DISTANCE TO NEAREST: Dia. of Well Casing FOUNDATION CONSTRUCTION SPECIFICATIONS PROBLEM AA Dia Of Well Excavation -1 Specifications TYPE OF WELL ❑ Manteca Type of Grout INTENDED USE ❑ Open Bottom Type of Casing - ❑ Tracy Depth o{ Grout Seal \ ; ❑ Industrial ❑ Gravel Pack n Delta �„at� n68 \`\ ❑ Domestic/Private Surface Seal Installed by X Other Depth [ 1 Eastern State Work Done ['1 Public APProx. Dep H.P. I I Irrigation Type of Pump Sealing Material (top 50') public wer is tic system permitted if p Repair Work pone C7 feet.) O Well Diameter �— Filler Material (Below��) available within 200 Well Destruction ❑ DESTRUCTION I 1 l v sap Depth REPAIR/ADDITION [ I NEW INSTALLATION [ I SEPTIC WORK' TYPE OF Other.� � serve: Residence— - Commercial— Wa table Installation will srtments Number of bedrooms�� No units: Capacity— osal Number of living depth °{3 feet: Method of Disp Character of soil to a d O of 3 feeType/Mt* Property Line�— SEPTIC TANK Foundation�� TREATMENT PLT.❑ Well PKG. Distance to nearest: Total length/size Property Line--------- ❑ No. & Length of lines Foundation LEACHING LINE Well C3 Distance to nearest: Number FILTER BED Property Line � Size �- 1 1 Depth Well �� Foundation� state laws, and SEEPAGE PITS Joaquin county ordinances, Ll Distance to nearest: I shall not SUMPS permit is issued, signature oaq DISPOSAL PONDS n is application and that the work will be done in accordance with San tors hiring or subcontracting g ansa re ared this that in the performance of the work for which thisor certify that I have P P 1 certifyrsons subject to workman's comp I hereby regulations of the San Joaquin Local Health District. I shall employ P ensation laws of California.California." Contrac rules and reg agent's signature certifies the following permit is issued, Home owner or licensed a9 ` Z o any P i{ that in the performance of the work for which this p I arson in such manner as to become subject to workman's co em' Y "1 certify pate. Complete drawing on reverse side. certifies the following: Dri].1iriCJ tion laws of California." inspections- Tonto lican must call for all required in�SL Title: The aPP � � D TMENT USE ONLY � .91 rea Signed Date Date Final Inspection by Application Accepted by Da 1 -e— Inspection by C),tl C7 Pit or Grout Inspe ❑ Tracy > `'-Fa386 Stk., CA 9`5201 6j81 C3 Lodi 3----6936 21 ❑ Manteca �3-71641601 E. Hazelton Ave., P.O. Box 2009, Additional Comrnents: ❑ Stk 466" DATE PERMIT NO. Applicant - Return all copies to: Environmental Health Permit/Services App CK>t RECEIVED BY AMOUNT REMITTED CASH of FEE AMOUNT DUE ( �� INFO 1 I . EH 13-24(REV.t/H 5) T cu 74-')6