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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> I <br /> Owner's Name KAREN MAGUL Address Phone <br /> I 17754 N. Hwy. 88 <br /> Contractor GOEMING PIIMP Address lockefordA License No.309031 Phone 7 <br /> �---ter -- <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR R OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />-- _INJ,EN.DEp-USE_ —TYPE.OF_WELL— PROBLEM_AREA_„CONSTRUCTION SPECIFICATIONS <br /> nindustrial �❑ Open Bottom ❑ Manteca s Oia. of Well Excavation Y Dia. of 0111 Casing1. <br /> C_] Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing— Specifications <br /> i't Public !.1 Other [I Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump - `. H.P. 74 HE -- State Work Done Added 10 ft_to_length <br /> Well Destruction ❑ Well Diameter Sealing biliterial & Depth <br /> Depth ` a i-ller-IMterial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-I 1•--REPA'IWX0DITION•( I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 lest.) ]� <br /> Installation will serve: Residence_ Commercial.-- Other (`bJ <br /> Number of living units: Number-'of bedrooms $ <br /> Character of soil to a depth of 3 feet: Water8 <br /> NCO <br /> SEPTIC TANK. ❑ Type/Mfg ; ""` '" Capacity No. Cts <br /> PKG. TREATMENT PLT.El'— -tit.yi, _. �i s.T .. �_ TMethod o !?i¢pDs <br /> _^Distance fa neaiest: `Well Fourid`efion Property Line � '' <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property <br /> cN <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS ❑ <br /> 1 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 <br /> rules and-_regulations-ofthe-S n•Joaquin.County-=F <br /> Home owner or licensed a s signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in suc nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followi nify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif r <br /> The applicant m r ired inspections. Complete drawing on reverse side. <br /> Signed X I Title: . BkDI . ___ Date:09/15/92 <br /> R PARTMENT USE ONLY <br /> Application Accepted by Date Z Area Z <br /> i� - <br /> f Pit or Grout Inspection by Date Final Inspection b Datr�i',c� z <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE 1 4-_.-1,& <br /> AMOUNT REMITTED CK H RECEIVED BY GATE PERMIT'Np. <br /> INFO <br /> . EH 13.24 IREV.1/M Si <br /> ? Est 14.26 V c <br /> � 1 <br />