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t 12.o SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL. HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 SCANNED l-tee P��' P O BOX 2009, STOCSTUN, CA .95201 Uo z. 92 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED • J� F o (Complete in Triplicate) 0 Application is hereby made•to San Joaquin County for a permit to construct and/or install the work herein described. This application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health � fServices. resse®© Rcity AddAS� I Lot Size/Acreage Owner's Name I U Cd P_ Gf ala Aydress Q1Z Z -57 WA lk-M=1�0 PiIQ m!`J Phone Contractor „ Address P®° 6�j (14 IT License No:9(7q_35-3 Phone-36720l'` 77 ` TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT DESTRUCTION 0 Out of Service Well PUMP INSTALLATION t -SYSTEM REPAIR 0 ' OTHER O Monitoring Well C7 FOUNDATION AGRICULTURE WELL OTHER AL FLD:- --PflOP-I-INf� ': DISTAN'�ET TO-N-E-ARE-ST:SEPTIC-TANK""bD`n� S-EWER'LINE'S -DIS-POS ER WELL= PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TIQNS �r n Industrial ,'Open Bottom, O Manteca Dia. of Well Excavati Dia. of Well Casing Cl Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing ee' Specifications a i'l Public fl Other✓ �'"7-1'Delta Depth of Grout Seal Type Grottt e , 1 Irrigation. Pf 1®.Approx. Depth I j Eastern Surface Seal Installed by /Trf J� i 1►� Ls Repair Work Done U Type of Pump H.P.:�_�_ State Work Done _ e Well Destruction O Well Diameter, s`' Sealing Material & Depth C Ap t9L 15 lvf t Depth �/ Filler Materiel b Depth -5 r TYPE OF SEPTIC WORK: NEW INSTALLATION,IJ REPAIR/{ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is r l 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 PKG. TREATMENT PLT. O Method of Disposal r- i Distance to nearest: Well Foundation P 4 perty Line I' LEACHING LINE Cl No. & Length of lines Total length/size ”`"' N FILTER BED 0 Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 11 Depth Size Number I f SUMPS LI DistanceAto nearest: Well Foundation Property Line , J' DISPOSAL PONDS O I 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 1 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 j certifies the following: "I certify that in the performance of the work for which this permit is issued; I shall employ persons subject to workman'scompensa- tion laws of,.Californis." The applicant must call for all requir d inspections. Complete drawing on reverse side. Signe Title: ce-- 4ylDate: a3 oZ DEP RTMENT.USE ONLY ' e \ Application Accepted by L Date 2, Area Z ` Pit or Grout Inspection by w Date� a "92 Final Inspection by 1 Date tr/q3 x Additional Comments: N ! Applicant - Return all copies to: San Joaquin County_Public Health rvices '�PrJiCe` I r Environmental Health Permit/Services t ) K. C1 t).e J J Pc) ..- j 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 i € FEE AMOUNT DUE AMOUNT REMITTED CEIVED BY DATE PERMIT'N0. INFO �y CASH # / � A-3 . 40 EH:'14-21'IREV:'t i'N s'1 t��. Q V _ { EH 162a F / UU o vc-