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APPLICATION SAN JOAQUIN COUNTY""PUBLIC HEALTH SERVICESR E° E ENVIRONMENTAL HEALTH DIVISION , IVED K 445 N SAN JOAQUIN --PHONE' (209)468-3420 -JUN 2 2 1992 I P O BOX 2009 STOCKTON CA 95201 ' ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR -FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) Application Is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules-and Regulations of San Joaquin County Public Health Services. �� Job Address _G�M C&,/�?.1[W L�A1 90 City Q�/-t�/� - Lot �Size/Acreage Owner's Name ATF-�C KESSZE2, . - Address ze � Iy_ N[J Phone ContraUor ress XNo. Phone (� I TYPE OF WELL/PUMP: - NEW WELL ❑ WELL REPLAC MENT ❑ DESTRUCTION Out of Service Well Gl -- = - - -PUMP INST-ALLATIONY❑-•_-ri---'-t!7•-^:` SYST-EM•REPAIR-L]44 _.-.d-OTHFR�C7- - Mo�itbring ll ��- DISTANCE TO NEARESrt:_SEPTIC TANk SEWER EINES -DISPOSAL FLD. PROP. LINE'"' r FOUNDATION AGRICULTURE WELLIs��nerr� OTHER WELL, PITS/SUMPS I t I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C1 Domestic/Private 0 Gravel Pack El Tracy Type of Casing_ Specifications i I'I Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation a �.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction C;@� Well Diameter 1,2 M fd Sealing Material & Depth Depth /, Filler Material & Depth � CM EA al � TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I „DESTRUCTION I I iNo septic system permitted if public sewer is i t available within 200 feet.l Installation will serve: Residence— Commercial Other bf Number of living units: Number of bedrooms Character of,soil to a depth of 3 feet: `h Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Four dition Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line # - SEEPAGE PITS_- A-I_Depth-�!_-= =-- Si:e Number --- - - - z SUMPS LI Distance to nearest: Well Foundation Propei6-_Line DISPOSAL;PONDS ❑ - ' 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 County 1 € Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for which this permit is issued;I;shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californla." The applica mu t--c or all-require i tions.-Complote'-drawing'-om' se-sidel A : Signed Title: Date: FO DEPA ENT U LY Application Accepted by Date res ' Pit or Grout Inspection by Date T� Final Inspection by Dat�rL/✓� Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health Services I Environmental Health Permit/Services = 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK G SH AEC VEO BY ATE PERMIT•NO. l EH 13-24 IREV.I i n W EH t4-26 r