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- ? SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION TH— lI� 445 N SAN JOAQUIN, PHONE (209)468-3420 P-0 BOX 2009, STOCKTON, CA 95201 � PERMIT EXPIRES I YEAR FROM DATE ISSU P (Complete in Triplicate) MA� 2 4 1992 Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joa4din County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ,; ��-Z s S�:r.�C� �Ye - LotENVIRONMEN' �- EAL� � Job Address t t, , City slaRm i Owner's Name mAddress rtt�dx V &I Nn 5 J C7-0Phone 1) 17-41- CAM(moot 53944•:«P6}e Contractor r 1 ddress icense No. I TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS re— 3 CK Industrial ❑ Open Bottom El Manteca Dia, of Well Excavation �S n k Dia. of ell Casing 0% Ca Domestic/Private kk Gravel Pack ❑ Tracy Type of Casing Pvc- Specifications I"I Public M Other n Delta Depth of Grout Seal't- Type of Grout + I I Irrigation g' 34qApprox. Depth I I Eastern Surface Saul Installed by Repair Work Done U Type of Pump H.P. State Work Done _ AR Well Destruction ❑ Well Diameter Sealing Material & Depth L�' Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is �1 available within 200 feet.l V) Installation will serve: Residence^ Commercial_ Other w 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, Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of linea Total lengthlsize FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number nAfNI CdNNTY SUMPS LI Distance to nearest: Well Foundation Property Line P��HEALTH SERVICES DISPOSAL PONDS ❑ VIRONi EN7AL HEAL'j 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 N 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: "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 must call for required ' spe¢tions. Complete drawing on reverse side. / Signed X ` Title: 1S,r®L � _ Date:ell FOR DEPARTMENT USE ONLY 0. Application Accepted by Date -a "��-- Are 0 1� Pit rat nspsctlon by Date final Inspection by Date Additional Comments: Applicant _ Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMI7'NO. + EH t`.�EN 3 24 1REV.iinsll. �y"1 1 r o� �,J 1J� �32J W �" � q /c;4 L4J l�