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TION FOR PERMIT APPLiCA Ji SAN 30AnUiN LOCAL HEALTH DISTRICT ON AVE.. sroc�c�oN, CA 1601 E. HAZE�T 46"781 Telephone (209) PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) l or install the woli'�herein descry-This application is for a permit to construct welldpumP and the tiles and Regulations of the San Joaquin uin Local Health District or No.1862 Application is her made to the San u Couniy Ordinance No•548 for sewage made in cornpliance with San Joaq PM Loa Health District. Lot Size 1J F u City g d C'Oiu Z- 1 Z Z 5 CII p� .- phone O� Job Address /�e{>'al2u�^ Pro�luc A X v Address " Phone Owner's Name Cj /� License No J IIIC DE ELL ❑ 6t-h Address CEMENT ❑ WELL REPLA .r m OTHER ❑ Contractory NEW WE tt SYSTEM REPAIR ❑ PROP. LINE TYPE OF WELLIPUM DISPOSAL FLO_ — PITSISUMPS �– PUMP INSTALLATION ❑ r,SEwER LINES OTHER WELL NEA TO RE �' ST: SEPTIC TANK tAGRICULTURE WELL DISTANCE 1- x FOUNDATION �. CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 5� l PROBLEM Well Excavatwn Specifications TYPE OF WELL Dia, °f dC ea IN NDED USE ii L3 Manteca Type of Casing Type of Grout ❑ Ope^Bottom Tracv ❑ industrial !' „ Depth of Grout Seal S rA G,ravel Pack ❑ Domestic C1 Ti p Delta ❑ Other Surface Seal installed by ori& Done Eastern State W 0 public j�pprox. Depth C3 H P ❑ Irrigation ' Type °f pump Sealing Material(top 50" sir Repair Work Done; ;❑ tic system permitted if Pu. ❑ Well Diameter Fiver Material(Below`�) SO feet.) Well Destruction Depth DESTRUCTION ❑ available within 200 TION 03: REPAIRIADDITION O Konito� NEW INSTAL LA i TYPE OF SEPT' iINRK: �` rCial Other�! J idence;� Comme .. -'' alar table depth rve: Res rooms Installation Number of No. compartments • � Number of living units. Capacity t: fl Method of Disposal soil to a depth o Character of 1f p TypeVMfg property Line ------ +. SEPTIC TANK . ndatron PKG. TREATMENT PLT.❑ Distance to nearest: Well Total lengthlsize w rty Line ------ SElNo{7& Length of lines Foundation PK( ❑ i n Well LEACHING UNE 0 Distance to FILTER BED 1" 11 Number Size Property Line epth Weil�� Foundation �- LEAt SEEPAGE PITS Joaquin county ordinances D Distance to nearest: FILTI SUMPS � ❑ :' rk wiq be done in accordance`with San Joaq ONDS - rk for which this penult is" DISPOSAL re Fred this application and that the wo rfo-manes of the wo or sub-co SEEP. 1 hereby certify that I have p pa „I certify that in the pe Contractors hiring following: nsatwn laws of California- persons subject to we" ant's signature certifies the subject to workman s c°^'7 permit's issued;1 shall employ SUMFEEP. rules andrtifyregulationsof the San Joaquin Local Health District. rnh ns this pe DI Home owner or licensed agent's as to becomework for wh• employ any person in such ma Performance of the wo I herek certifies the following' "I certify,that'" the pe r# f �U lrtC� rules ai tion laws of California." ions. Complete drawing o^rave rse r 7 Qata: le { st c 11 for allHorne u'red ins employc The applicant j' Title: ENT USE ONLY certifies Signed (� EgR DEPARTM pate " tion law # i The app ted by '} Final InspeG*m by Signed Application Accep Date Pit or Grout inspection by ❑Tracy Stk. GA` Applicatic Add"itional Comments: 1 ❑ Manteca M-71041601 E» Hazelton Ave., P. 20C 0 Stk4663-6781 a°do: E -tal Health Pemutl 7 -'� Pit or Gro pent- Return all cop} N_ _NA cK Ri Cl INFO BY OATf Additional FEf AMOUNT DUE AMOUNT REMITTED CASH ❑ Stk 46 a INFO t Applicant °. ♦ EH 7}24(REV.1/ts 51 4� a w — - ✓ EH 14-25 :k