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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PAYMENT 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE _ISSUED SEP SAN lOA 1 .5 1992 (Complete in Triplicate) CWNTY PL18LIC HEATH SERVICES r Application is hereby made.to San Joaquin County for a permit to construct and/or install the frbl`k' � T�ieb #j•[�IQ , (�I application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Colony Public Health Services. Job Address ��'' 42 city City 'x�,_( Lot Size/Acreage Owner's Name - f `� < <= Address �/�zPhone Contractor - 7� � Address � �'� License IVo, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION C] Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ]. OTHER ❑ Monitoring Well L� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑0 Manteca Dia. of Well Excavation Dia. of Well Casing C.] Domestic/Private Cl Gravel Pack Lel Tracy � Type of Casing_ Specifications I'1 Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Depth ,l I Eastern Surface Seal Installed by Repair Work Done 5 Type of Pump Ifc�9 H.P. ` State Work Done Well Destruction ❑ Well Diameter if Sealing Material 8 Depth ` Depth s Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet) "1 Installation will serve: Residence—_._ Commercial,.Y.. 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. 0 Method of Disposal Distance to nearest: Well Foundation— Property Line LEACHING LINE L"1 No. & Length of lines Total length/size FILTER BED C1 Distance to nearest: Well Foundation Property Line I m SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 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 hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Iowa of California." The applicant must or all reg ired inspp,ctio s mplete drawing on reverse side. l /it//+✓ �r Date: Signed K ��ri Z Title: , _ FOR DEPARTMENT USE ONLY Application Accepted by Date �Z Area Pit or Grout Inspection by Date Final Inspection by Date �S Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 FEE AMOUNT DUE AMOUNT REMITTED tICK RECEIVED BY DATE PERMIT NO. INFO � ��CC �^ /� ` �j�, +� . E„1124UIEv.fix5) / � �TSt"D �d � L6O� � 17 `�f �Z L`�d EH 11.28