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APPLICATION. ; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 s PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby rade 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 PublliJc/�Health Sery cels. /r i Joh Address / V N Ol r/ I 01V City `+J Lot Size/Acreage Owner's NameA Tc- i C e- Address + )9 g7, ^ Phone � 1�/ oa / 3&�PCantrattor 0� hone S _O, .7! i TYPE OF WELL/PUMP: NEW WELL 11 WELL REPLACEMENT ❑ DESTRUCTION;ii�t of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I-.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ --Specifications---- CI Specifications-CI Public C] Other n Delta Depth of Grout Seal Type of Grout i I I Irrigation Approx. Depth I i Eastern Surface Seai Installed by Repair Work Done 0 Type of Pump H.P. State Work D Sealing Material 8 Depth .3� Well Destruction Well Diameter �: Depth &iller Material & Depth �� PE OF SEPTIC WORK; NEW INSTALLATION i I REPAIR/ADDITION i I DESTRUCTION I i (No septic system permitted if public sewer i available within 200 feet.) -� Insta tion will serve: Residence_ Commercial Other Number o iving units: Number of bedrooms — Character of ' to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal C Distan nearer ell Foundation Property Line LEACHING LINE 0 Length of lines Total length/size j FILTER BED _ Distance to nearest: We Foundation Property Line 1 SEEPA ITS 11 Depth Size Number SU S Ll Distance to nearest: Well Foundation Line ) POSALPONDS ❑ ' I hereby,cenify 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 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this pa it 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 ertify 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 California." The al Ica t m s I or all r a i ti Complete drawing reversesi Signed /� � �*--�-� - Title:. ©- � �� Date: / ' / �,_„•��..,L a 6FOR DEPARTMENT USE ONLY Application Accepted bOL y Date 6- 10-92LArea f1 Pit or Grout Inspection by Date l-i Z`b Final Inspection by41- Date V'Z U q. I Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services 5r �q .LA-/ Environmental Health Permit/Services f 445 N San Joaquin, P d Box 2009, Stkn, CA 95201 FEEK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO: . Em 13.24IREV.I/n51 �`D DD r- H6 W.4VlI� R2,2Z.Z9 01 1{.2a �.i/�/ !