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t APPLICATION` ILAl� 3� r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . ENVIRONMENTAL HEALTH DIVISION z . U` 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. CityJS } — Lot Size/Acreage Job Address Owner's NameBob b I }nn Address 660 Bristol SttxktOn Phone x6A— , Contra Addressp License No. 377923 Phone 887-3554 TYPE OF WELL/PUMP._...-�-- .:.NEW.WELL,?k,....%C. WELL REPLACEMENT Ci DESTRUCTION ❑ Out of Service Kell ❑ 3 } PUMP INSTALLATION � SYSTEM REPAIR ❑ OTHER ElMonitoring cell C3 DISTANCE TO N11 EAREST: SEPTIC TANK SEINER LINES DISPOSAL FLO, f PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial 2 Open Bottom ❑ Manteca Dia. of Well Excavation 14 DiaYof Well Casing :�S6 DomewiclPrivate ❑ Gravel Pack ❑ Tracy g Type of Casing_ Ste 1 i Specifications'-�c — .. Public t Ili Other n Deit' Depth of Grout__Seal —gyp Type of Grout_ cement I I Irrigation .Approx. Depth I I Eastern Surface Seahlnstallad by^ I Repair Work Done L3 Type of Pump sub 'ry "j H.P• 7 State Work Done F t Sealing Material & Depth Well Destruction i ❑ Well Diameter r ..,• ., I Depth Filler 1Ma erial•Ar.Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION f I DESTRUCTION I I INo septic system permitted it public sewer is available witHin 200 feet.) i - Installation will serve: Residence_ Commercial_'; Other- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: +` Water fable depth u` w Capaoity No. Compartments SEPTIC TANK. ❑ Type/Mfg _ .b - �'. .Method of Disposal PKG.1TREATMENT PLT. ❑ Distance to neatest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property,Line SEEPAGE PITS I I Depth -Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line.•--` � DISPOSAL PONDS ❑ t _ 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 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 certifies the following: "I certify that in the performance of the work4or which this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." The a scant st call f all equi d inspections. Complete drawing on reverse side. Signed Title: Corporate Secretary Date:- 8/17/92 F D ftARTMENT USE ONLY Application Accepted by Date Area �? E- Pitd ,Grout nspection byData ! Final Inspection by Date d+J k, J Additional Comments: 120— ZZ.6 Applicant - Return all opies to: San Joaquin County Public Health Services Environmental Health Permit/Services { f 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ePERMIT'NO. INFO / $H1S3-2 rREV. i n 51 G 1 _7 I— s e EH 42a - r