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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sap 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 93 City Stcci±mL_..-- Lot Size/Acreage 40M C�n Owner's Name Address Phone Contractor UhateX Address License No.55210 TYPE Of WELL/PUMP: NEW WELL IN WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well M DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E-1. Industrial ❑ Open Bottom ❑ Manteca a.of Excavation R in— Dia. of Well Casing [I Domestic/Private X] Gravel Pack ❑ Tracy Type of CasingSch- Specifications I'! Public 0 Other n Delta Depth of Grout Seal 7) ft'- Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by DH11rar- Repair Work Done LJ Type of Pump A --_ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material 3 Depth 4LZO C=it to a,rface Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Sue Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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(tiring or sub-contracting signature certifier the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicantm t call r:all re�edis ti, a. Complete drawing on reverse side. Signed Title: O mer Date: Jul q29 1992 FOR DEPARTMENT USE ONLY Application Accepted by r q Date �' ►ea �� Pit or Grout Inspection by Date �1 0" r- Final Inspection by Date Additional Comments: 5 Lk&Lr, hV9 110.2m.01 Applicant - Return al copies to: San Joaquin County Public Health Servic s CA]J tt.ae Q� 6151C) Environmental Health Permit/Services i �l Pei' CJC* 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DVE AMOUNT REMITTED CK INFO I CASH RECEIVED BY DATE PERMIT'N0. . EMI 3-24(REV.r/K 51 51, 7-5qsl MM 92- }g] EH 11.26 �NAJ f 1��