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• APPL•ICWTON • ^ �� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC Sf (v ENVIRONMENTAL HEALTH DIVISION p p 445 N SAN JOAQUIN, PHONE (209)468-3 �1arf�t ��aa P 0 BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 1 YEAR FROM DATE ISSUEDOCT 2 9 1992 (Complete in Triplicate) ❑ fiN�AMt1NF1A`L`''II(HFALTH Application is hereby aide,to Sm Joaquin County for n permit to construct and/or install P a Wolk/h >!21YtSLrs2lDed. 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. �D/n,411.69 Lr 5:/J.b,- A;�oo,4 I�IEY a+f Job Address � r City Mtea-' Lot Size/Acreage -O'2 p-Cn /tau' ,� lrr.s s-Eyec}Ac ca^,(iawr Owner's Name Gdt /�ro4ucf"^tSfe�ef Address 37SA I✓•y4IA Sr .r:�ef7D. ��'1-4C��Phone Sfa 146-424E Contractor�rr£-(rt ntta4�a PF' Address 22fa E Yoxsw�C Mlan�t<e� License No.651-339 62 4 Pnone2o9- aT 92L8 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERS Monitoring Well ,�,rerarbry Ben -(Srp MQ DISTANCE TO NEAREST: SEPTIC TANK Nv�l6 SEWER LINES N'Ai£' DISPOSAL FLO. /&Al£ PRO LINE a>k�N r FOUNDATION Now£ AGRICULTURE WELL Na^f£' OTHER WELL No's PITS/SUMPS r{fi INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom Manteca Die. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public fl Other 11 Delta Depth of Grout Seal Type of Grout appeoi�+y 6nr+^S —Approx. Depth I I Eastern Surface Saul Installed by spell Work Done 0 g�Tryp..ee of Pump H.P. State Work Dons_ Well Destruction 13OMNI Diameter 0 t^<L Sealing Material i Depth N1Q.+etsxt..+F Depth `Z-C'f"+ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( 1 DESTRUCTION I I INo septic system permitted if piljw sewer is availa=depth Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of and to a depth of 3 feet: table SEPTIC TANK O Type/Mfg ::c�1—typoperty No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Fo Line t LEACHING LINE ❑ No. i Length of lines A Total length/size FILTER BED ❑ Distance to nearest: all Foundation Property Line SEEPAGE PITS 11 De Sire Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL POND ❑ I hereby cenity 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 Sen 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 of sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa tion laws of California." The applicant mu call i required impactions. Complete drawing on reverse side. �J Signed Title: �"/7 Date: Il0 V FOR DEPARTMENT USE ONLY Application Accepted by � ° V DataL � Area- Pit or Grout Inspection by w D to ` 7� Find Impaction by 1 Date Z' Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services �� S-73Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT.�/�.DttILI E:rAMOUNT REMITTED AASH REEC�E1IVyED BY DtATE /� PERMIT'NO. . eta 13 24 laEv.i,s s� YI-O D I7 r - 0 1 `� ! 1 4 P2 z- -73