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lit a y � -� =•-�,i x "�" '`� �it'�� SAN JOAQUIN LOCAL HEALTH DISTRICT 16p1 E. HAZELTON AVE., STOCKTON, CA elephone 12091 '66.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED lComplcle in i rip!icatel .,.Olt[u the 5,m"'n un Local ilt•alth pizu+ct fur a ermd to construct and or Install the work herein de5clibed.This application is P Apt,bra hon is heiehy t ulaiions of the San Joaquin made In complia.Ice.w-[1'San Juagwn Ceun:Y Otd,ndnca No.549 for sewage o:No.1862 for well/ and the Rules and Rag i Local Health DIS;ur.t �CA Lo: Jul)Address r / Address 1[1I..._13.`Ip:�� Intf`l�s�F_LJfI�-. Phors��l:J�-.J-i.��...fiJ"T.l+C}- Owner's Narne/L��l��l� � � r,Lt1�/ 1 l�. '7-7 ie�3 / 0 3 l _.--.t it le- t1�5 q 'J f I _Phanc� ! !��" L, Q.�_� fJs- '( A ss Z 7-�.11� -Litcnse No.�R�-i-- - - - Coulraclw .->t~-es JV.{l DESTRUCTION 1,3 TYPE OF WELL/PUMP:- NEW WELL I' WELL REPLACEMENT I; _ PUMP INSTALLATION i? SYSTEM REPAIR I} OTHER><MW rTC1i 'Lty tV�4. DISTANCE TO NEAREST: SEPT4C TANK SEWER LINES __---- -- DISPOSAL FLO. PROP. LINE - ---�- _ AGRICULTURE WELL OTHER WELL. ... PITSlSL1M^S __.. FOUNDATION ._ _ -- --.�.�v-- INTENDED USE TYPE OF WELL_ PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` — Cl Industrial I-'Open not"' 'Manteca Dia.oI Well Excavationes ------ Da.of!Yell Casing _ -I Tracy Typ:of CzsingpY��Ct�-�-�- - Specifications �DomesliUPrivate yel Pack `-_-- Typo of Grout U Public ��i-1 Delia Depth of Grout Seal Cs Irrigation _flppfOK. peplh i 1 Eastern Surface Seal Installed In/ -�.--+- - a of Pump I/-A - H.P. --`--- ----- State V7ak Daae Repair Work Done it TVf -' Well Destruction ❑ Well'Diameter Sealing Material pop 50 1 Fillet Material RBclow 50'1 Depth - is1,�----� 1 TYPE OF,S TI—r-WOR K: NEW INSTALLATION f, REPAIRIAODITION i'. DESTRUCTIOPI L1 avail blew thin 20stc 0 feet.)ed if Public sewer is InstallT[ron wit serve: Residence _ Commercial Othe+ Nu mher of living units: Number of bedrooms - - -,Wrier Table depth Character of soil to a depth of 3 feet: -_ No.Compattments - ---- _N.._.-Capacity SEPTIC TANK C? Typel MIR Method of)ispos+i PKG.TREATMENT PLT.Ll Propcny Lina...__-- Distance to nearest: Well -_._-._Foundation p� LEACHING LINE L1 Na. 8 Length of Ines FILTER BED CI Distance to nea+est: Well -� _ Foundation _-- Property Line Number SEEPAGE PITS 1.1 Depth -��-�~--- F,._ndation Property Line. -- SUMPS 1.1 Distance to nearest: Well DISPOSAL PONDS t i _ { Thereby certify that 1 have prepared this application and that the work will be done m accordance with San Joaquin county ardina•;ces,state laws,an l rules and regutaiiom;of the Sar.Joaquin Local Health DiWict. anis is issued,I shall not Home owner or licensed agent's signature certifieS the following:"I cell'fy that m the purio:manco of the work for which tnI pe ; Act To workman's compensa employ any person in such manner as m become subject to workman's compensation laws of California."Contractor's hirin or subcantrar-deg signatum certifies the tollowing:"I certify that in the performance of the work for winch this permit is issued,I shall empla ,� 1 lion laws of Cafifornia." X Complete drawing or Tse side. The applicant--t t call Inr alt requned ins ns. --_/��,1 Tina: ff1E _ Date:_ � 4 Signed Xi -. _ 1 R P ENT U84 ONLY k i � J` -j�' � Area Date_ _- i Application Act^ptad b -1 �f/.f1�-•--�- - - t -' "- �1. (',�, Date Final Inspection by �- Date Pit qr C+taut�s On by ..�.{(�e..{,1��`" { - Additional Comments:�� !!1 G Stk 466,6781 ❑Lodi 3693621 d Ma rata 673-7166 L3 Tracv 835_ V,- - Applicant ell copies to-Environmental Health Permit/ 1601 E. Hazelton Ave.,P.O.BOK .Stk.,CA 95201 f FEEAMOUNT DUE AMOUNT REMITTED � RECEIVED BY DATE PERMIT'NO. .EH 17-24;REV.I -a, EH 1424 r