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SAN &UIN COUNTY PUBLIC HEALTH &ICES nl �� ENVIRONMENTAL HEALTH DIVISION I-A , 445 N SAN JOAQUIN, PHONE (209)468-3420 R�,CEI� P O BOX 2009, STOCKTON, CA 95201 () (� 3 1993 PERMIT EXPIRESI YEAR FROMDATEISSUMN J'OA JI,;;V ,,; (CompleteENVIR LI OC-'I Nha Application is hereby made to San Joaquin County for a permit to construct and/or install the t�M/�ei�'laj desFy'}�ad. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1062 and the Rule, and Regul'ai '6"OA' San Joaquin Co_ L Public Healt Service,. Ul S ` /1 /', Cit Lot Size/Acreage �1.C1 1-146Job Addres �(� t" 'y" ' ��J(.0• �C /O -l_/"7iV`f,/ �3, YX /O/Gi.Z.0.. L)Q ✓t_ /�C-i�l�iC�-i Owner's Name - address Contractor - "e nC, Address t cense No(— 4A1,03 TYPE OF WELL/PUMPS NEW WELL LP- WELL REPLACEMENT C, DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSiSUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u C! Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation L"5 Dia. of Well Casing y C! Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_— PVC. Specifications Public .i-rfhher fl Delta Depth of Grout Seal A. Type of Grout lb ^"" I Irrigation /_Approx. Depth I I Eastern Surface Seal Installed by Lk1 Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter r� Sealing Material S Depth ag n-�.--n - /A.-/rS+ 'C 5 Dept _ Filler Material 6 SCA� � +e-1 r4 -*L hf- f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 1 INo 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 LEACHING LINE ❑ No. & Length of lines Total length/size t Cl FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina _f Cl DISPOSAL PONDS ❑ J 1 hereby comity 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 candies the following: "I cenify 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 must call for all required inspections. Complete drawing on reverse side. C _ r.- Signed X1 a luL L X,l...l.`�fL ..n� =Title: C`r'\ o CLQ i�0ate: �� �, � .U�,[1�F'O � )- DEPARTMENT USE ONLY Application Accepted by T""'""" "' �" -" Dare �^ y�AAr�reea 56 Pit or Grout Inspection by �1• — Date Final Inspection by '� u""`^'N" Dater Additional Comments: Cn 0 /I n✓P r' rrf. yv,�Zy\ L"00 -C'4 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services C.XY1 111 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE I PERMIT NO. EH 13-24(REV.i/n51 EN a 28