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SAN JOAQUIN COUNTY PUBLIC HJAE4RA -PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVIS �HEALTHDIVISION 445SAN BOXOAQUIN, PHONE 2009, STOCKTON, CA95) I P , 'TP O � AUG 2 7 1992 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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 C Joaquin County Public Health Se/r�vices. �/y IZ35 Cosf AIPIne. Avuve, Cit —"4}9'1 Lot Size/Acreage N 0, AL Job Address Y r�� 31 oZ Oe►�1a.,J*,, S""+Q 900 vJts4o.+ tt (� Owner's Name Ame ritelm re-0 L>'&4-G 012 Address W01"S F Tstc 7szt 4 Phone �1 1 3-2.33 Ir=r'�% 41"MI CA s+-. Contractor WtS ryG�MaI" Address Ra..c l.n Cor vee. C14 License No.r_t7ssy9,9 Phone Z 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 7 Sdr SEWER LINES 'r Z8' DISPOSAL FLO. 2',TSZ PROP. LINE 101 FOUNDATION 39 r AGRICULTURE WELL �SC OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing $j [I Domestic/Private Gravel Pack Elat Tracy Type of Casing_ YC Specifications 11 I'] Public Cl Other n Delta Depth of Grout Seal S y-76 r Type of Grout 5010 I I Irrigation 51' _.Approx. Depth I I Eastern Surface Seal Installed by Wn,'1 1 er Repair Work Done, U Type of Pump �!�_ H.P. State Work Done _ Well Destruction ❑ Well Diameter t w�L. Sealing Material & Depth ..' �I-$�► Depth approK. 100' Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is V, available within 200 feet.) J 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 Capacity No. Compartments _ PKG. TREATMENT PLT.Cl Method of Disposal S Distance to nearest: Well Foundation Property Line �v LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 permit 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 certify that in the performance of the work for which this permisi s WvhJgl�pr 6?y*"ns subs ct o workman's compensa- tion laws of California." J �C�il�t�VUN l Y-PUBLIC HEALTH SERVICES The applicant ust all ►equ�tions. Complete drawing on reverse side. ENVIRONMENTAL HEALTH DTVISION Signed X Title: 6e01c<.I54- SPECTATD FOR DEPARTMENT USE ONLY Application Accepted by t DateA7- � Area Pit or Grout Inspection by - � I/t (/ /b(�ate �Final Inspection by Oate Additional Comments r C�' �"KH►.. W Applicant - Re urn all cops s t an Joaq n ounty u is Health ervic Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 ®' FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH --po . EM 13.24 IREV,i i x 51 EH 11.26 F