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i i FA"I JOACIWN LOCAL HE!kLTFf CjtsrIIICT ;t;01 E. HAZE.TON AVE., STOCKTON, CA Teb!phonr: (;QJ) aG(;67fil PERMIT FXPIRES 1 YEAR FROA4 DATE ISSUED (CnrnlNelrr u) Tnphr�dlr:l - Avobcalw,.s r'.rvehy made Ir.the Sd. .!n.uluu.I Oral}Ir•,dih f)r;.tnrI ler a 1 ma tri 'w ne.rdl for work hvrern twsenbed Thi;application is • tde in con.ph'i v vnth San Indquin Cr n,nty J:drn,.rr I-rh,.[.;1 for srweq.)or Nu Irnr7 4v--il own,.rid the Rulds and He.•u!;rtions of in,-Sar,Joaquin lucid 11,1,11111 0"•u.:t r ^ I Job Address .lL� rr�•'' _ '.i,l�-rr; I . Cdv ' .'__.iCl , < /t�''�! PM - -.--- -- - 1� r>I nt Sire 1L'_ Owner's Nana, l- f -_, ! C.�/�/r�_ _�r�. �j('v�. __. Phone COIIt LIL ler �`. r �'-•)�.� (( ivr'rrst _�. r -..(_!.. /i -License Noz/ JG°7�Phone(� �-Q//� TYPE Of-WELL%-'JMP NEW WFLL I ' WEI.1.REI" "•':}MINT i i DESTRUCTION PUMP INSTALI ATION I: SYSTEM ?FPAIR i OTHER i-I DISTANCE (0 NEAREST: SEPTIC TANK ___-__._- SEWER LINES _-_ DISPOSAL ILD._.__.. PROP, LINE FOUNDATIONAGRICULTURE WELL _ OTHER WFLL_ _..___ PITS/SUMPS _ INTE.NWD I)SE TYPE OF WELL PWN)LEM APEA CONSTRUCTION PECIF!CAT10NS I 1 Industria! l,Open Bottom Manteca Dia. of Well F11Ca\dliOn--_--_ _ Dia.of Well Casing r i Domestic/Private I.I Gr.Ivc1 Pack , Tracy Type of Casing______^_____. Specifications I': Public. 1 1 Othrr I 0011 Depth of Grout Seal Type of Grout I 1 Intildtron Approx. Depth I Edslorn Sedate Seat Installud by _—__- +epae Work Done i 1 Type of Pump _-. --___- H.P. .----_-_. _ _. State Work Done -_--.--_ --- -- .Well Destruction Well Diameter _ S:::linq Material Itop 501 Depth Filler Material(Below:iO.1 TYPE OF SIP11.0 TK: NLW INSTAI I ATION-- RLPAIWAODITION; OL'i1ftUCTiUN I (No sopor.syaten)permrRed of pubilc rawer is -\// avdddble within 2(b feet.) .nstallation will serve: Residence .__ Commercial_/� Other_-__ -. Number of living units: .__-. Number of heeb�o/0.ms./- .,, Ch,racier of soil to a n`cP11 of 3 feet_—.Aa- �_ �y C)/_fir{__._ __ /_ _��"""'''/,W,arer table depth — SEPTIC TANK XI TypeIMfg / ' ��- / �!..�_-. Y�/tj -�� "ryo.Compartments O \ t..[.�hly� l_. _ Capaat PKG.TREATMENT PLT...l / / , /y Method of Disposal Distance to nearest: Well i'_C-_'I/ Foundation L,.r-,_! Property Line-1 rn /1 i-- --- LEACHING LINE No.&Length of hoes _1�Q—�(`.<,: IiL%2 Total length/sine. .411 FILTER BED I I Distance to nearest: ell e-f Foundation JE"` Property Line SEEPAGE PITS Depth _ -T_.—Sire -_�... �?__. Number - -- r .. SUMPS 1 I Distance to nearest: Well ___-- Fuundation .. .._._— Property Line (7 DISPOSAL PONDS I i (a I hereby certify that I have prepared this application-.ed that the work will be done in accordance with San Joaquin county ordinances,state taws,and n rules and regulations of the San Joaquin Local Heald,District. Home owner or licensed agent's signature certifies the follnwing:-I certify that in the performance of the work for which this permit is issued,I shall not employ any person in such manila,as to become subloct to workman's compensation laws of California."Contractors hiring or subcontracting signature certifies the following:"I certify that in the perforar.ce of the work for hich this purmit is issued,I s',all employ persons subiect to wor mkm in•s compensa- tion laws of California."{{ The applica�Lr 41JpgairA i factions.Com t/ rawin on ra/vSg�rse side. Signed X.__ ��//�`////�/_C 4e—�Title9—cr!Ld/IL) ��! [�L'__ Date: --aXt'----- - R DEPARTMENT USE/ONLY APPlicatiou Accepted by —i �..� ---_--- Date �- Area— Pit or Grout Inspection by — - Date Final Inspection by '�/C �f� �/\�— Date /V Additional Comments: - -- ---- -------- O Stk 46133-6781 F7 Lodi 369-3621 C Manteca 823-7104 3 Tracy 836-6385 Applicant- Retcru all copies to:Environmental Health Purmit/Services 1501 E. Harelton Ave.,P.O. Box 2009,Stk.,CA 95201 r EE ALIOUNT DUE AMOUNT REMITTED CAS'/l RECEI JED BY DATE PERMIT hJ. . ER 13.24 IaEV.r rrr li EH 1.26 i Y�