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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION AUG 2 7 1992 445PNOSAN OXJ2009,OAQUINS, PHONE TOCKTON, CA)95201420 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 pServices. �Jtl 1 qrp� 12 �QS4 A► )�� Aytm ,a- s o h Lot Size/Acreage to Job Address P we SA' j.o�.t City_ Owner's Name, Amer'CAn Eta[ ZSR Gro!PAddress D v i 1 cam, T x A 1�3 Phone 1 3 -2---4-3 F 4-;kcQ,r-a 1 s Contractor �� : -�c-� Address Cry License No.�57SS`15�� Phone IL, 2� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK >T*O SEWER LINES 'J Z br DISPOSAL FLO.I M PROP. LINE FOUNDATION 319r AGRICULTURE WELL >SQ OTHER WELL—2-5 1:�'_ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 4 Dia. of Well Casing El Domestic/Private )k Gravel Pack ❑ Tracy Type of Casing_ PVL Specifications I"1 Public El Other P Delta Depth of Grout Seal ke '2 4 - 2 h Type of Grout A 1 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by bc.,114ir- Repair Work Done U Type of Pump MA H.P. State Work Done_ Well Destruction ❑ Well Diameter 2 Iw�� Sealing Material & Depth 4-4a Depth Q j2f2CO 1( 1 � Filler Material & Depth 550 Qe..�1er•.�`�E.�G Q*`wQ�� 4o vid r t. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) 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 O Type/Mfg Capacity No. Compartments n' PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in thB ttr0M�tif�n_ ttiie than+ �RVMot employ any person in such manner as to become subject to workman's compensation laws of J 1�1Q�r @ukScou`u� g signature certifies the following: "I certify that in the performance of the work for which this permit is issue , I fitiljl6$t}o woririfdti compensa- tion laws of California." SPECIAL PEi�l� �T The app lica ustcaalllf�forr�all r/e�q�uiirre�d�insspections. Complete drawing on reverse side. Signed X__n7�1`Sli.1➢rJ .ZS t r�J►/� Title: 6,eo\cea S Date: Z- R DEP R MENT USE ONLY q Application Accepted by �* Date Area Pit or Grout Inspection by a c � Final Inspection by \ `' , Date Additional Comments: Applicant - Return 1 copies to: San Joi oPublic Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO �7 J . EH 13'24(REV.ti951 �o EH 11.26 v 1