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f .� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION N 445 N SAN JOAQUIN, PHONE (209)468-3420 IP P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) Application is hereby made to Ban 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. City 1 (1801 N ClementsC�� _ Lot Size/Acreage Job Address - $ { M„-rrr,ri ca W Wi 1 1 i AmS _ Address Phone I Owner's Name ��,a X � Contractor Purviarlce Drillerst ngWdress P• 0. Box 64 Linden License No. 377923 Phone 887--3554 TYPE OF WELD/,PUMP'. NEW WELL [A WELL REPLACEMENT n DESTRUCTION C1 Out of Service Well ❑ t Monitoring Well �7 PUMP INSTALLATION I { SYSTEM REPAIR ❑ OTHER ❑ 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 6 5 in f_7 Industrial ❑ Open Bottom ❑ Manteca � I Dia. of Well Excavation Dia. of Well Casin 34 Domestic/Private ❑ Graver Pack �-,-, L] Tracy Type of Casing_ steel Specifications 1'I Public Cl Other n Delta e of Grout ` } Depth al Grout Seal 240 TypCeMMI i3k Irrigation 32r1 Approx. Depth 4 (,Eastern Surface Saul installed by t SUS? H.P. 1 1 2 State Work Done Repair Work Done U Type of Pump Well Destruction O Well Diameter Sealing Material & Depth : Depth :Fillet Material & Depth 4- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIfllADDITION i I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.l z 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 ❑ Type/Mfg ^ i Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance`t nearest: Well l Foundation Property Line f LEACHING LINE .Cir Total lenthlsize No. & Length of lines g I FILTER BED ` (;1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number - SUMPS LI Distance to nearest: Well - FoundacicA I 'Property Line DISPOSAL PONDS ❑ 7 1 I hereby certify that i have prepared this application and that the work will be done iri-�ccordance with San Joaquin county ordinances, state laws, and�,� I rules and regulations of the San Joaquin County f 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 no 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 peiinit is issued, I shall employ persons subject to workman's compensa- tion la alifornia.' The applicant st cap.for II r ired,' speetions. Complete drawing on reverse side. _. 12/28/92 Signe Title: Tate Secretary Data: C FOR DEPARTMENT USE ONLY Application Acceptedby Date `` Area t Date �P' Final Inspection by Date Pit or dro t Inspection by 3 - + Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Services " ^ + Environmental Health Permit/Services t 445 N San Joaquin, P 0 Bax 2009, Stkn, CA 9520 FEE AMOUNT DUE AMOUNT REMITTED + , CASH RECEIVED BY DATE PERMIT'NO. INFO , u �a jq� yy D�nnp + H 53.24 tREv.t/n SI ` 14.26 L