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SAN JJUIN COUNTY PUBLIC HEALTH S /ICES VIRONMENTAL HEALTH DIVISIO R;g9JVZJ to 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FEB 2 6 1992 (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the 6W W) rtE9q. Thir application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the RulepM[?f61W(CM oo''••San Joaquin County Public Health Services. Job Add ressOnnn t' � r`-AIK. �l City, 10 r Lot Size/Acreage Owner's Name Address � r1J`=� f Irl��//CEJ •''jC�� Phon L�� - 1 -Sim -rteLX-Z-L--- Contract �' ' kA ddress / �: ! cense No 3 hone TYPE OF WELL/PUMP: NE LL W L REPLACEMENT n DESTRUCTION Ll Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER G Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLDbPROP. LINE FOUNDATION . �� 1r AGRICULTURE WELL `C CTHER WELL PITS/SUMPS I ' �Z INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS )� L-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation " Dia. of Well Casing CI Domestic/Private 0 Gravel Pack ❑ Tracy Type of CasingSpecifications yr I'1 Public Ether n Delta Depth of Grout Seal / Type of Grou ' ^a I I Irrigation _.Approx. Depth astern Seal Installed by Repair Work Done 0 Type of Pump Su A H.P. R St s Work Oone: rti Sealing Material & Depth ' rte ' -to Of Well Destruction O Well Diamete C KI r-I ` Depth 7 Filler Material & Depth TYPE OF IC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. fi Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 subcontracting 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 ust call for ell wired inspections. Complete drawing on reverse side. Signed X_ Title: Date: FOR DEPARTMENT USE ONLY 1 1 Application Accepted by 4 Dace Area Pit or Grout Inspection bx � '` Date 313.L-7 Y Final Inspection byDate Y�r.�.�- •$.s f ►,non At r t o W -k I t•n/ C.J S S L&A-LV-V. L 0 n t 5-Te-- o•4,- n4u J210a Additional Comments: T S M r,s < re 1 Applicant - Return all copies-to: San Joaquin County Public Health Services �e -tQ ►'t1�v— ��51) Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IEE AMOUNT DUE AMOUNT REMITTED NFO CK RECEIVED BY DATE PERMIT NO. I ��p/ X��/1 CASH /) A . -57 EH 13.24IREV.�,Mst flJ !� 4OL/w, (a EH 14.16 '