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SAN J JUIN COUNTY PUBLIC HEALTH S DICES "T�VIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 RpmayEl P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) FEB 2 6 1992 Application 1s 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 Joaquin County Ordinance No. 549 and 1862 and the Ru61\Aft fi rprQ; pn Joaquin County Public Health Services. v+u n V. PERMI VIES Air 'Job Address f6�jY..� '��j-,`�QmiL" ye,. 1� pat UI City. - 7 I Lot Size/acreage 'l Owner's Name t��htl-/ !l _ � lam%_ Address X771 �.s/rt/It= �t_l�w�l� Phon6 Contract IY'- , sAddressjJWYj4" t Adlicense Ndr: ho TYPE OF WELL/PUMP: NE%Al/ 'ELL ELL REPLACEMENT M DESTRUCTION.Q Out of tervice Well ❑ PUMP INSTALLATION ❑ SYS EPAIR C OTHER f M nitoring Well V d c.5 e. w e-J � DISTANCE TO NEAREST: SEPTIC TANK,>_MQ:'� SEWER LINES DISPOSAL FLDJ�PROP. LINE FOUNDATION �LVfl AGRICULTUREWELL,.JV'4 OTHER WELLA�PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 70 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f.l Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casingie , /r Specifications I'1 Public RT Other fl Delta Depth of Grout Seal 3-Tf�t_—_/1 Type of Grot T I I Irrioation __._Approx. Depth I I Eastern S14rf ce Seal Installed by - -- i - Repair Work Done U Type of Pump r H.P. �ork onq. _ t Sealing aterial i Depth t'' r - �tilE+t; Well Destruction O Well Dia met r ,,- �/f1:ti'er!`r' Depth Filler Material i Depth 1' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 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: "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 canities 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 spOica st call fo_r required inspections. Complete drawing on reverse side. Tid r f r t Date: Signed FOR DEPARTMENT USE ONLY q Application Accepted by :d� Date ` Area q Pit or Grout Inspection by Data 3 3 ( -�— Final Inspection by `ll Date / I� 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 FEEAMOUNT DUE , I AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO . EM 13.24(REV.1/%51 EH 14.2E