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- 12 0>7 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 SCANNED =. I-q_o t 3 3 P O. BOX 2009, STOCKTON, CA 95201 0. 22 `f2 u PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r, o<, (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 Services. Job Address h City IJA 1 Lot Size/Acreage Owner's Name ` �4]IJ Gt fS��[, a "dress � �� l-i�L1M� i�� t�Gf Phone - Contractor h Address P0. B6N�'7�; (94 j d License No:;5tT 353 Phone3 -6a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION O Out of Service Well PUMP INSTALLATION SYSTEM REPAIR, O f OTHER O Monitoring Well C7 t DISTANCE TO NEAREST:SEPTIC-TANK L' tC—='SEWER`0NES" ,---"'--' --DISPOSAL FLD:--��----- —PROP7-MNEC - _ FOUNDATION AGRICULTURE WELL OTHER WELL= PITS/SUMPS 1 INTENDED USE TYPE OF WELL ACBLEM AREA CONSTRUCTION SPECIFICATIONS �r Cl Industrial ,'Open Bottom, El Manteca Dia. of Well Excavation Dia. of Well Casing Pack L7 Ca Domestic/Private O Gravel Tr`acy Type of Casing��.G�--° Specifications •` �"i�, I'1 Public Cl Orther✓ �l`Delta Depth of Grout Seal Type Gropt a Irrigation 9'_?®.Approx. Depth I j Eastern Surface Seal Installed by-U,2 Ze�f 21 ri 1 vk 40 j Repair Work Done U Type of Pump--'Ztg1 J&e d H.P.i 6Z�� State Work Done _ Well Destruction ❑ Well Diameter; Sealing Material & Depth Depth ",` Filler Material & Depth �'- 3 TYPE OF SEPTIC WORK: NEW INSTALLATION;-l. REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is x � available within 200 feet) Installation will serve: Residence_ Commercial_ Other ! t Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth <" SEPTIC TANK O Type/Mfg # Capacity No. Compartments j v k PKG. TREATMENT PLT. 0 � Method of Disposal ( Distance to nearest: Well - Foundation Property Line j LEACHING LINE CI No. & Length of lines Total length/size e FILTER BED ❑ Distance to nearest: Well Foundation Property Line # SEEPAGE PITS 11 Depth Size Number j 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 r 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 permit is issued;I shad employ persons subject to workman's ompensa- tion laws of California." _ The apppl-iccaan�t must call for all reqd inspections,. Complete drawing on reverse side. SignedY,_--, uir Title: --\,��r Date: a-3 oZ DEP RTMENT USE ONLY t f Application Accepted by L Date '- l Area Pit or Grout Inspection by w Date La 8 "92 Final Inspection by Date Additional Comments: (� N ; Applicant - Return all copies to: San Joaquin County Public Health rvices `� O� �P!-�J1i[e Environmental Health Permit/Services { �.�. Cw-e 1 C)PU` J 4 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE ! INFO AMOUNT DUE AMOUNT REMITTED CASH CEIVED BY 4 DATE PERMIT'NO. 1 �3 EH 11.2a V a� if _ $