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f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r <br /> i ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br />' P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> j (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. /�j <br /> I <br /> Job Address Z,7 �iV `-'� City v� Lot Size/Acreage <br /> Owner's Name / Address �' T`� Phone 9 12 <br /> 00-7 <br /> Contsactor x�,li Lis' Address% "'✓jy ` License No. 0770 Phone 3�t y,ZJ" <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT+r DESTRUCTION t of Service Well ❑ <br /> PUMP INSTALLATION-?5 SYSTEM REPAIR Ll OTHER C Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK/ E0 SEWER LINES DISPOSAL FLD. ZO PROP. LINE -/0 <br /> t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS'-`% /ft <br /> -111-Industrial ❑ Open Bottom— _C Manteca_ w _Dia.,of Well Excavation _ �- Dia._of Well Casing <br /> Domestic/Private `R Gravel Pack C Tracy Type of Casing_ IO -Specifications Y� <br /> I'I Public Ct Other n Delta Depth of Grout Seal l ___`_ _ Type of Grout <br /> I I Irrigation �' -.Approx..Depth I I Eastern Surface Seal Installed by -5*eeC <br /> air <br /> Rs Work Done 0 Type of Pum f✓'� � H.P. !L State Work Done rte] <br /> P P ,rr <br /> Well Destruction + °UYfell.Diameter/ Sealing Material 5 Depth <br /> Depth °'�Oer + Filler Material b Depth <br /> I. TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDtTION I I DESTRUCTION I I INo septic system permitted if public sewer is j <br /> available within 200 feet.! <br /> Installation will serve: Residence____ Commercial f Other <br /> Number"61 living units: Amber of bedroomsl ; <br /> Character of soil to a depth,oT 3-feet Water table depth <br /> SEPTIC TANK ❑ Type"IMfgs Capacity No. Compartments <br /> PKG, TREATMENT PLT, Cl 1 � f 1 Method of Disposal <br /> L Distance to nearest: Well I Foundation Property Line r, <br /> LEACHING LINE Cl No. & Length of lines Total length/size I <br /> r <br /> FILTER BED Cl I Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I r" Depth Sire ' Number .' <br /> SUMPS LI Distance to nearest: Well Foundation Property Line ` <br /> DISPOSAL PONDS O �x <br /> 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 <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent'saignature_certi_fies.the following: "I certify that in the performafte of the work for which this permit is issued, I shall not <br /> ampioy any person in such manner as to become subject to workman's com nsatioy laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: I'certif that in the performance of the work for whicTt this eFrnit is`tii ued;I shall em to <br /> " y pe p $ y persons subject to workman's compensa- <br /> tion taws of California." <br /> The applicant must call f r all tsquired inspections. Complete drawing on reverse side. <br /> Signed X465�4 _ Title: f�f..aA"`+ ,� Date: <br /> 7- 7-92 <br /> FOR DEPARTMENT USE ONLY ;• <br /> Application Accepted by ` Date - Area Q <br /> Pito Grout nspection by Date 7 l� Final Inspection by Date <br /> Additional Comments: (�v! Oic� f Y (6p0 / <br /> z~ <br /> Applicant - ReQ"- , ies anoaquin o y ubl Hea th <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED GKCASrA RECEIVED BY ATE PERMIT NO, <br /> � <br /> WF� 01 <br /> . EH,3-24IREV.IJK5) P� l l� Sif • -� Q� yiz <br /> a� t <br />