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{ SAN A( UIN LOCAL HEALTH DIST siiCT 1601 H/ EL T ON AVE., STOCKTON, CA elephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appi n describ . This cation is madlecnt compliance with Sano)Joaquin County ordinancle No.549 for sewage or permit No. 1862 for cwe{!/ install the pump and the R l s and'R gulations of he San'Joaquin Local Health District. / -cc,, C/t2hO�P� 4[s Ire City G(?cz�' Lot Size PM Job Address Address Phone Owner's Na /• (era Sa vt n�CJ4 (41S M►Z�Z't T i... �Ip1►o- „rte aw g to V Ia t►, S - .S CcGJ 4C -br1%t*-CS Address 067V a� S4-0);fr"Q4A! License No.46132 y Phone mg Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El f Moat wWe0 PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER PR J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a I f [IIndustrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' i l Domestic/Private El Gravel Pack O Tracy Type of Casing —<".d0 I��G Specifications CfeM ¢ ut I"1 Public Cl Other n Delta Depth of Grout Seal ~:I- Type of Gro A. I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by �KC g Repair Wofk Done ❑ Type of Pump H.P. State Work�Q)o wes� / r,nar V,{i 1 w Well Destruction, y� Well Diameter _T_ Sealing Material (top 50'1 �.� a �I rrlt�,i�olir� t+'c��J't Depth ~�r Z0 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION 1 I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well _ _._ Foundation _ Property Line LEACHING LINE I.7 No. & Length of lines Total length/size # FILTER BED Ll Distance to nearest: Well __ Foundation _ Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ( i Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS 1-1 I 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. certify that in the performance of the work for which this permit is issued, 1 shall not Home owner or licensed agent's signature certifies the following: "I employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which per s issued, sh¢II employ persons subject to workman's compensa tion laws of Calif ia." 1e )h Q 71% Lw-SU tion _d/I The applicant t call for all r u'r inspections. Complete draw,Ag on reverse si _ ,ftic=op- eK.. Date: 11 �i A S 7 Signed 0W FOR DEPARTMENT USE ONLY G f � _ 1� C✓I `�} Application Accepted by Date Area rr �+�5 1z,tStF� Pit or Grout Inspection by �p vi l�a��S �i Date/ Finalavt Date inInspection by �/ L/ Additional Comments: S-ee- - 0 Stk 466-6781 O Lodi 369-3621 ❑ Manteca 1123-7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ' . EH 13.24(REV.i m51 :E C EH/436 . ..:y:.,,..,4•;.� ..... ... ... ::. ., ._ .... �-,,ag. _;err,