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LC SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RfC E 1 445 N SAN JOAQUIN, PHONE (209)468-3 P 0 BOX 2009, STOCKTON, CA 95201 OCT 2 9 1992 PERMIT EXPIRES 1 YEAR FROM DATE ISSUID NM�NTAL MEALTfi (Complete in Triplicate) P�RMI�/5�RVJQ95 Application is hereby made to San Joaquin County for a permit to construct and/or install t e wor b Sn Ibed. 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. I / A ,�] /- mC�.I��M DeRsJr "r 5:4 rbn- Hi�'FO4 '� Cir M�CCe- Lot Size/Acreage —0-Z ar -t JOD Address y La, gr ,r w.i�4c��n lJdf /�ro�r.rf:�.s t � 37S N• I✓. c'f Ia r Owner's Name Adtlress Ki SWC Phone 5-lo) 14/e- 4Z42- Adtlress �tC-(rt aG r.4�ans ••OcpF 226 E•YOSCvxAf- MOL-1kca- License No.GS1-3391,24 PhoneZo9-367-9268 Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well 01 OTHERY, rl n toring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ic'� er>�ry (q� DISTANCE TO NEAREST: SEPTIC TANK A10"E SEWER LINES No APL DISPOSAL FLO. xis OE PRO LINE e�w V; `l FOUNDATION Ne"z£- AGRICULTURE WELL A's's& OTHER WELL /JO"ig' PITS/SUMPS �106r Sf+ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Dia. of Well Casing Indindustrial ❑ Open Bottom Manteca Die. of Well Excavation Type of Casin9Specifications [IDomestic/Private ❑ Gravel Pack C1 Tracy - I'1 Public 1-1 Other FI Delta Depth of Grout Seal Type of Grout I �,i,��ry AAs _Approx. Depth I I Eastern Surface Seal Installed by *.Pau ork Done U Type of Pump H.P. State Work Done _ •g�,..y 0 incl Sealing Material L Depth Nie +Ci2.wcit.L* t•{r '&+ 'u (S'/•) O-2S'�'F Well Destruction ❑ �Mell Diameter Depth "Z I f+ Filler Material a Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I available INo system permitted it p!*',sower is avawithin 200 feet.l Installation will serve: Residence _ Commercial _ Other Number of living units: _ Number of bedrooms Character of wil to a depth of 3 feet: —VQatef table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Fotion Property Line _ 1 LEACHING LINE ❑ No. 6 Length of lines l Total length/size FILTER BED ❑ Distance to nearest: ell Foundation Property Line SEEPAGE PITS 11 De Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL POND ❑ 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 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 persons subject to workman's compensa tion laws of California." The applicant mu call I required inspections. Complete drawing on reverse side.m Signed 7 Title: u./�// Date: pp Application Accepted DY FOR DEPARTMENT USE ONLY Data � y V a � f wLC' Datee Final Inspection by ') Date ' ' Z Pit or Grout Impaction by t Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Boz 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH c>q " ,f, I (_/(1 11s) I�� 1 (art' It I I61QZ z-3�3