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SAN JUIN COUNTY PUBLIC HEALTH Sh-,,,i(ICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PA KIWEAr PERMIT EgPIRES 1 YEAR FROM DATE ISSUED Al c`ety (Complete in Triplicate) ED Application is hereby made to San Joaquin County fora t SAN JQ�/�� 1992 application is made lac permit to construct and/or inata]��1lA,�tIAFJB T t�re,.>oeV4'�,fi cribed. This compliance with San Joaquin County Ordinance No. 549 and 1862 and"E�IbI1dlLRtXaL1'dnp�of San Joaquin County Public Health Services. -•'n+ , Job Address e,ttiW �. MC(�(.Q(/D •rtvp. City <MLot Size/Acreage 5G t k-� aU 3 gt524 3-CYco$ 3 �f E7�3 Owner': Name Sr,J036i�4s MEDIC X- J1 _ ddress 004 �O$ , sirwim/j Phone Contractor S PIECi?Z V M Address�$.i S rya f-Lc S Kx' icense No.�/ Phone'465 / 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION A Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK n1A SEWER LINES 0rhJou� DISPOSAL FLO. A/A PROP. LINE Jd FOUNDATION AGRICULTURE WELL OTHER WELL y! PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 29 n Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ PVC, Specifications -55-H I1 Public XO tj Il'�1�11,k Delta Depth of Grout Seat _ Type of GroutLl�f W CE16 c1�n I I IrriUation pprox. Depth Eastern Surface Soul Installed by�p�r(_ L(M Repair Work Done U Type of Pump H.P. State Work Done _ IZZS Well Destruction Well Diameter Sealing Material & Depth ",VA- `Is M,f A-17- Depth 'Depth 'f�o Filler Material 4 Depth r-7 6 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I Mo 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line ti LEACHING LINE ❑ 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 canify 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 m call for all requtr spections. Co I e drawing on reverse side. S5E At� M G� Signed Title: IZSa Date: A / FOR DEPARTMENT USE ONLY Application Accepted by Q� Date 2__ Area V3� I Pit or Grout Inspection by Date! Z3 nal Inspection b Data Additional Comments: Applicant - Return all copies to: San Joaquin'County Public Health Services / Environmental Health Permit/Services g.�r 445 N San Joaquin, P O Box 2009, Stkn, CA 95 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIV D BY GATE PERMIT'NO. VY . EN,3.24(REV.r/n$) /A /nU ,441 6 9 EM,4-2e t(Yl ii ttf{// 4