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APPLICATIOm FOR PERMIT SAN ->OA I,4 LOCAL HEALT11. DIS"RIGT 1641 E. b.A1E'LTON AVE., STM70, CA Tel6f+one (209) 45£1578. - PERMIT NO. _<7 -_i,^ P£RvIT EXPIRES 1 YEARFRO*+ DATA ISSUED DATE ISSUED Komplete in Triaiica:e) Application is hereby fade to the San Joaquin .oval iieeith i3istrict far a permit to ccstrsact an°/or install the work lens n described, This application is grade 'n eompl4an'ce with Sar J04quin County OrGinance No. 509 for sewage or No. ISS? for swell/pump and the Rules and Regulations of to San Joaquin Local Health District. .lob Address x _ Itii i 4AAI.0 Subd i v i s "on Owner's hamsa@. la/JL` Address FIG, 1 Phone Contractor's Fiance _�';G,Bi�' , ;1s/�✓�+'.t7 License No. � 2harre TYPE OF !!lPJMP WEX_. NEW WELL WELL REPLACEr4ENT OESTR"t1OTION .� PUMP INSTALLATION SYSTEM REPAIR r C 1,=, OTHER DISTANCE TO h£AR£ST: SEi� iC'TANK_ r SEWER LINES i GISPOSAL:FL0_'-,`� .. PRO, LINE _�. FOUNDATION AGRICtiLTURi WILL OTHER WELL » PI'S1515 INTENDED U E r . `.. TYPE OF WELL PROBLEM AREA CONSTtU TI% SPECIFICATI7N5 � j Industrial F-1 Open Bottom ]Manteca � Dia. of Well Excavation D Domestic/Private _ Gravel Pack Tracy ilia. of Well Casing s t I j publ is Other; DeIta 3 1....ilrrigation Ty Approx. Eastern 'F t of lasing _. i� Cathodic Protectidin ., Depth Specifications (__)Geophysical Deoth of Groat Seal l.,_j Other l'yoe of Grwt Surface Seal Insta?16d by Repair Work DoneYpe T o. fH.P. [j Pump ,.....w •_„__. State Rork Done Well Destruction i 1 well Diameter Sealing Material (ton 501) Denth rilier Material (Below 501) .. TYPE OF Si PI It ikORK: NEW IhSTALLf4TION REPAIRlADDITION (iio septic tank or se"ge pit permitted if public sewer is r available withih 200 feet.) Installation will serve: Residence ✓,,, Covvwrcial Other a `•Y,,, Number of living units: j Number of bedrooms, Lot size r 7f Character of soil to a depth of 3 feet: r —� Water tabie depth SEPTIC TANK Qd Type/Mf _�+±.L " Canacityr tments- pKGG. TREATMENT PLT. Type/Mfg ,Capacity %ethod of Disposal : SEYtAiy£ SYSTEM Distance to nearest., Well Frzimd0tioh`x Pr, erty Line � DESTRUCTION _Id ° ._... -AEC _ LEACHING LINE No. & Length of=lines A-"./ Tota`1-4engthisize FILTER BED Distance to nearest: Weil J.Foundation Property line ' SEEPAGE PITS L=jDepth Size '� Nu+er r 3 SUMPS L 1 Distance to nearest: Well Foundation I/¢ Propert; Line r . 31SPOSAL PONDS I %, i 04 U� 2Z 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I Hance owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this PeM: t is issued, I shalt not employ any person in such manner as to become sub ect to wor*iront compensation laws of California." Contractor's hiring or sib -contracting signature certifies tine following: "I certify that in the performoce of the work for which this permit is issued,'! shall employ persons subject to workzan's tomptmsation laws,nf California." he applicant must c 11 for all required i pections. Complete drawing an reverse side. Signed k '' Title -r; Date: jA! 3o fj _,9--_. F A TMf'iT USE ONLY � . Appl :cation Accepted by , `Area`_.__ . �' Stk . 66-87'81 -=ice Additional Counts: Lodi 389-3821 Pit or Grout Inspection by Uw e" ,;'� " ' Manteca 823-71CA Final inspection by µ� D�te�il�?'', C2', Tracy $35-6385 Applicant - Return all copies to: Environmental tteaith PormitlBervices 1601*E. Hazettcn Ave.. p.0, Box 2009, Stk., CA 952Cl `. FEE BASE AMOUNT DUE AMOUNT R ITTEt1 RECEIVED BY04TE � PERMIT X10. i FO Etc 13-24 REV, 10/82 10182 Sino t 14-26 .. '.,