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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES CIVC ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 OCT 2 6 1992 P O BOX 2009, STOCKTON, CA 95201 �-MN JOr Q01N CO,'.JNTy BUG HEAl_1-H SEriVfC I- PERMIT EXPIRES 1 YEAR FROM DATE ISS 'irct?fVlti4ENTAL rlIL "(H Uli/; I ;u (complete in Trip licate) work in made to San Joaquin County for a permit to construe aendo1862install and the eRules and eIlegulationsdof Sane Application is hereby y n County Ordinance No. 5 9 / application is made in compliance with San Joao CI—er Joaquin County Public Heals Servi Lot Size/Acreage Jr PAI)1 SO Q et 1 �-� RIP- job Address � • � � Phone e Address tZ b Owner's Name License No.W$-4-21 Phone Address DESTRUC}CTION Out.of Service Well tContraclo WELL REPLACEMENT ❑ OTHER C1 i` Monitoring Well y ? NEW WELL Q , b TY.. E OF WELL/PUMP: SYSTEM REPAIR ❑ pROP. LINE i PUMP INSTALLATION DISPOSAL FLO. k f 7 SEWER LINES �---_--PIT515UMPS�� ___ """ "OTHER-WELL� --� DISTANCE TO NEAREST: SEPTIC TANK =AGRICULT� URE WELL —^�'_ '- ""-R FOUNDATION - - pfiQgLEfUI AREA CONSTRUCTION SIP J " TYPE OF WELL V ^��-- pia. of Well Casing s TiNTENDED USE p Manteca Dia. of Well Excavation Specifications ❑ Open Bottom I }lindustrial 0 Tracy Type of Casing Type of Grout — I ❑ Gravel Pack Depth of Grout Seal 1-1 Other [-1 Delta I ipublic r Surface Seal installed by ✓ I I FlrriOation Approx. De�pth� III Eastern State Wo Dong t �. al Pump „]�— H•P. Repair Work Done Lk- ,ype Sealing erial & Dcpth Well Destruction Q Well Diameter Filler Material & Depth w / 1�. Depth rmitted it public sewer is available within 200 feetA r. ' TY RE OF SEPTIC WORK: NEW INSTALLATION I I RIk EPAIRlADDITION l I DE5TRUCTiON I } {No septic system 1 ! Other �----- Installation will serve: Residence Commercial — \ Number of bedrooms�---- Wa;er„table depth Number of living units: L Na..Compartments t Character of soil to a depth of 3 feet: c4acity-- of Disposal SEPTIC TANK. 0 Type/Mfg t Method L?.�! ' j ""• .Property Line Distance to nearest: �1-- PKG. TREATMENT PLT. ❑ Foundation �--- { Well L f ' Totallengthlsizs LEACHING LINE 4A, Cl No. & Length of lines Well' Foundiftion_��---- "Property Line C1• Distance-to nearest:•� 1 FILTER 9EQ� � � ' Number SizProperty Line e SEEPAGE PITS l l Depth Foundation ---- L1 Distance to nearest: Well —�-' SUMPS A l L� DISEPOSAl--RONIIS T�f --- ' ' l ' .htireti certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an l Y performance of the work for which this permit is issued, I shall not rules and regulations of the San Joaquin County g: Home owner of licensed agent's signature certifies the followin I certify that in the Pg l arsons subject to workman's compensa efn loy`any person in such manner as to become subject to he work for which compensation permit laws issued,California." employ ptor's hiring or sub contracting mpe signature P I certify that in the performance certifies the following:" tion laws at California." /0 O,.�1 •� The apptica t est call or all re red in ctions.�C Coin drawing on reverse si e. pate:, { Title: $ignadi X FOR DEPARTMENT USE ONLY �L k d Date Area za", Application Accepted by f Date`p We f— — Final inspection Pit'or Grout Inspection by ��----------- Additional Additional Comments..:, opiesto: ECounty Public vices Re /Services Applicant"- $ Environmental 445 N San Joaquin, p O Box 2009, Sticn, CA 95201 `s• M .� DA PERMIT'NO. 4 I� FEE AMOUNT DUE REM17TE0 CK REC IVED BY i INFO ♦�1L�`JL�+ . EN 1324iREV.11inss EH 14.26 1t