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s r APPLICATION R PERh11T SAN JOAQUIN LOCI l SALTH DISTPICT 1601 1 HA7.ELTON AV: ri f OCK.ION, CA Tt11e0hone 12f ) 466 6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) nt,t,,.tr,.• the Son Joaquin Local He Nth Dretrrct for a pwm,t to construct andror mtaa the work herrn rMtcnMM Ths a"*cttroo rs t,• r •,. I•iartuin Counryr)rdmance No 9A9 for sewagrr or Nu. tf162 for wellrptrmp and tho Rubs and Requlat"m of the San Joaquin ...... . '%+(_,, 7(-7 So(10 1 15 It?d. City (-IrAT -. Lot Sir 4c n c rrwrrers 4.ine ' • • ` r^/� ..)TAddress C.�•-rPhone .)�•S 'L.��r I "otr,u.fl.a e, r(� (. r'.-`�U/�I'I.I�L Add:e•ss 11744_5�:.�/1'1f:�.�IC/Q/V._�dLrcenae NO-;;VY—('—(-Phone S v��( TYPE OF WFLL PUMP NEW WELL V WELL REPLACEMENT i' DESTPUCIION U PUPAP INSTALLAT�IO�N� [ SYSTEM REPAIR 1' OTTHrE�R� C1 DISTANCE TO NEAREST SEPTIC TANK -LL SEWER LINES 1.0-tyDISPOSAL FLD/.w PROP.LINE Lr- FOUNDATION .eLc-V1.:.-_ AGRICULTURE WELL 'C—T- OTHER WELL__ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial J{Open Bottom 1.1 Manteca Dia.of Well EResval ion r Dia.of. of Casing Jr K Domestic Prrva!p Gravel Pack 11 Tracy Type of Ctyini;l T S� Specification Fubhc Other (_;Delia Depth of Grout Seal �n r _Type of Grouts'-a I�z"nt l 1 Irrigation �Al'Approx.Depth C.Eastern Surface Seal Installed by Q,,-7&SyL(.a --- Repair Work Done Type of Pump H.P._-�_ —._State work Done Well Destruction Well Diameter Mtakng Ylateri>al crop 50 t — ----.. �� Depth Filter Material(Below 501 _. -_ _ ---- ---------- J TYPE OF SEPTIC WORK NEW INSTALLATION 17 REPAIR/ADDITION I I DESTRUCTION . (No septic system peorwtted i1 public sewn is avarivble within 200 feet 1 lostallahon will serve Residence— Commercial__ Other �l Number of i•v 1g tarts. _. _.- Number of bedrooms-- _ e Character of so;l to a depth of 3 feet: ____ Water table depth SEPTIC TANK Type/Mfg _._-- -------- Capeeity No.Compartments --- _ — PKG TREATMENT PIT. Method of Disposal ------ Distance to nearest: ___--Distancetonearest: WellFoundation—_ ProperfrLne r LEACHING LINE No.8 Length of lines __— __ Toth lengthrsim-_-___ crLTER RED Distance to nearest: Well Foundation Property Lite --- SEEPAUE PITS Depth _—_—Sue-_---_.-------___ -- Number----- -- 1 SUMPS Distance to nearest: Web---___.__ Foundation_ _-__ Property Line— — DISPOSAL PO':DS \ I hereby certify that I have prepared this application and that:he work will be done in accordance with San Joaquin county orditwinces,state laws.and rules and nqulations er ttw San Jaecuin Local Health District. Home owner or lice-seed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued.I Snarl not . employ any perso-n such manner as to become subject to workman's compensation laws of California.-Contractor's hiring or sub-contrachng sgnatuns certifies the folio,wmn 'I certify that in the performance of the work for which this permit is issued.1 sho employ persons subject to workman's compensa- tion laws of Calhtorn r." The applicant ust ;loll fou all required i pections. Complete drawing on reverse side. Signed X L>�,iC.�./� .�.i.) IL - — - - Title: LL�1tiLL��.� t Date. FOR DEPARTMENT USE ONLY X,G/ Application Attentnd by Date Pit or¢root ins / //� � sA Fine) L!rL ! r (' .pecbon by 1_ a-� stn by Additional Comments. _ / Slit 466-6781 Lodi 3W382/ 11 Manteca SZ3.7104 I 1 Tracy M6385 Applicant- Retu,n all copies to:Environmemal Health Permit/Services,1801 E. Hazelton Ave.. P.O. Boa 2009, Stk., CA 95201 IEE AMOUNT DUE AMOUNT RfIrlilTED H RECEIVED By DATE PERMIT NO. iNfO -- 00 •H t1 24 iRFv n++s26