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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PAYMENT 445 N SAN JOAQUIN, PHONE (209)468--3420 RECEIVED P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUID AUG 0 5 1992 (Complete in Triplicate) SAN JOAQ(JIf4 C011N",.-Y PUBLIC Hr<AL T l•1 SE::WCCS Application is hereby made to San Joaquin County for a permit to construct and/or install application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public/'Heealthh Services. 1 Job Address l QES M60. Skee,:L Cityr � Lot Size/Acreage �. Owner's Name S'�C]G(�-1011 — Address �_ I $ Uk Phone 4 9Y y`3 Contractor e ��il Address a License No. 3�t03 7S Phone Y16- &YSI TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 5 DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER gK RCQo4w4 Lt,ng�Wg�cl DISTANCE TO NEAREST: SEPTIC TANK tX70 SEWER LINES > 100 �'� DISPOSAL FLO.>)Qty PROP. LINE fW�nc(( FOUNDATION AGRICULTURE WELL ?j-QiL. OTHER WELL_2 PITS/SUMPS Jr tC�.C�ur1G INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT DNS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 0 $1 Dia. of Well Casing n ft f r [I Domestic/Private Gravel Pack 0 Tracy Type of Casing_PVL Specifications I'I Public 1-1 Other VD.ItaSi*C.f;10^ Depth of Grout Seal 2 A Ahofe-5Ve4"Type of Grout t k I I Irrigation _.Approx. Depth i I Eastern Surface Seal Installed by _C6 11Pr -- Repair Work Done C Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth pUM +A japy-rDepth Filler Material & Depth r—" TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is Q available within 200 feet.) 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size i FILTER BED n Distance to nearest: Well Foundation _ Property Line r SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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: "1 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: "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 must calf for all requir d inspections. Complete drawing on reverse side. -G Signed X 4: " Title: s Date: j2C.�vvA.7AIDkSlre.Crj If FO DEPARTMENT USE ONLY 2� Application Accepted by ~ i Date Area Pit or Grout Inspection by ° Date �a ` Z�Final Inspection by ` Date 1'1� .. Additional Comments'111` Applicant - Return all copies to: San Joaquin County Public Health Services ,. Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. '10,� INFO b ✓] �`[[ . EH13.24-2e(REV,tiKSl 6-7 ,On Q O�- EH 1 V