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E'f R � � trJ P✓�1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES _ ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46&-3 �� 1 ` P 0 BOX 2009, STOCKTON, CA 95201 XJ R 1 YEAR FROM DATE ISSU PERMIT EXPIRES A (Complete in Triplicate) R 24 1992 Application is hereby made to San Joaquin County for a permit to'construct and/or insta described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 an '�SC �na of San Joaquin County Public Health Services. ESP r� C , 7 Job Address S City tl Lot Size/Acreage Owner's Name S ir" C 6 n Address t C� 953�' Phone Z'Q`� d all-,�J ri�',6- �- 91,00 1 9 f �_��„�io��''o'�� '' C�t16) Z�-q�o3 Contractor�C=-=t Address S License No. Phone TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT I-1 DESTRUCTION 0 Out of Service well 0 PUMP INSTALLATION )j SYSTEM'>';06 DISPOSAL L7 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK 414 -- SEWER LINES L�!d; DISPOSAL FLDAJ A- PROP. LINE-L.5J9 1- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Sej-- Ft'�Vfe__ I T R Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l nGj' Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingY►31S4,-�l Specifications Y4 t"61 1'i Public Cl Oth ? n Delta Depth of Grout Seal Type of Groutl�ff&Lg' X► I i Irrigation ,� pPox. Depth 1 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth 0 Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial— Other Number of living units: Number of bedrooms n A Character of soil to a depth of 3 feet: Water table depth v SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthtsize O FILTER BED ❑ Distance to nearest. Well Foundation Property LineIV SEEPAGE PITS 11 Depth Size Numberl �F SUMPS L3 Distance to nearest: Well Foundation Property LineZ5AN 4 1992 DISPOSAL PONDS ❑ f0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Q6jFF lAw -'ews, an rules and regulations of the San Joaquin County T/AL Fp T`yj/IC Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permh r issE j all not r> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting si 4ture certifies the following: "I certify that in the performance o1 the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican us t call f r all required inspections. Complete drawing on reverse side. / Signed x / /!/frit' Title: &20/ ST --- Date: F D ARTMENT USE ONLY Application Accepted by Date Araaol Pit or rout opection b Date Final Inspection by Dated 9 Additional Comments: / E Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2008, Stkn, CA 95201 Oen-' j FEE AMOUNT DUE AMOUNT REMITTED rt H RECEIVED 8Y PE DATE RMIT'NO. MFO . EM 13.24(REV.1/145 EH 14.26 "lid 6J Pito �s