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' SAN 6iQUIN COUNTY PUBLIC HEALTH ..,IVICES � ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 OCT s�ry Jo/tf 1992 PERMIT E%PIRES 1 YEAR FROM DATE ISSUED ��/��/ ?f�tnV�. (Complete in Triplicate) �rJrLit�J114 `f �1_Fs Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein descr' �tL XhAs•n v application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 13M �5D`'T4A C0fJ-T"_ ST- City �}v[1ciOt� Lot Size/Acreage Owner's NameCHf::)J(z0^S uSN QZOWLTS Ca Address Phonr� to _-e6 S(tr_3 iz�t.nprJ C A c14��-0 04 Contractor W1J� 0t,JI (bddress 1105 LA''AYQI0t t-fJ r COW0EQ License No.C57-'ffiPhone s« 8S- 61 TYPE OF WELL/PUMP: NEW WELL-_ WELL REPLACEMENT n DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR C7 OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK '> 1011 r-r SEWER LINES 7 100 f"f DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation c Dia. of Well Casing N(VA VES: F) Domestic/Private O Gravel Pack ❑ Tracy Type of Casing__R0-1 46 P.4 C_ Specificationsy `-`40 f"1 Public Other BgIT�"� Depth of Grout Seal 7-0 fee-r Type od Grout tJ C E- W/ I I Irrigation — Approx. Depth �I'rEastern Surface Seul Installed by D-P- _5 Y. B�`'��'�T� /� Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other a Number of living units: Number of bedrooms UP Character of soil to a depth of 3 feet: Water table depth .11 SEPTIC TANK O Type/Mfg Capacity No. Compartments ^ PKG. TREATMENT PLT. 0 Method of Disposal (0) Distaqr.e o nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to Weare Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: 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 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 all required inspections. Complete drawing on reverse side. Signed X tip`"-" . Title: �'�Eo L or� ta--, Date: a�- FOR DEPARTMENT USE ONLY �1 Ir t)1tf� Application Accepted by Date Iy Area 2-9.00 Pit or Grout Inspection by /�--m t Date I I Final Inspection by �. Date g� Additional Comments: 04_514C \N f' COS+ 1122,r175 PZkMLJ6 10/1 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO p CASH/ y��/ ► Iq �j '2 . EH 13.24(REV.,r x 5) -r ,'�$`f 1' I (� ` L- f 2 q2�V EH 116-M `