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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BO% 2009, STOCKTON, CA 95201 PERMIT F_ _ IRES 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. 5h9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 4M2 Pacific-Axlp-_(offsite, AIT 4 Bk 1l'YR n CityStnkiCn Lot, Size/Acreage M� Sq ------tMft. Owner's Name Address ]LO, BOX 915.5,_Sart 12arm.,_(A 9/u P3 PhonO Contractor W�Stex AddressP License No.99-9198 _ Phon TYPE OF WELL/PUMP: NEW WELL & WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR M OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD• PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSiSUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f_1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing �.l Domestic/Private (X Gravel Pack ❑ Tracy Type of Casing Specifications i'i Public Cl Other ❑ Delta Depth of Grout Seal Type of GroutNFnf, CEMMt I i trrigatton Approx. Depth I I Eastern Surface Soul Installed by T)H11Pr Repair Work Done 0 Type of Pump —WA H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth EMi7mi f•E; 4L% ,St= to c, dke Depth Filler Material & Depth# TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.l 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 CI No. 8, Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation Property Line SEEPAGE PITS 11 Depth Size Number n�J 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, f 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, t shall a Contractor's persons subject to workman's signature tion laws of California." The applican ust ca"r all requirVdnspqno, Complete drawing on reverse side. Signed Title: >= Date: 1992 FOR DEPARTMENT USE ONLY C� 5 r Z,1 Q 0 Application Accepted by 77 Date c Z res Pit or Grout Inspection by Date Final Inspection by Deta rr•� _2 Additional Comments: �itW G �� Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8y INFO CASH DATE PERMIT Np. Ch EH;IAS. s, $�. $�, 2 3 }�/l � MWlO t Mw11