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SANTJIN COUNTY PUBLIC HEALTH SEr— ES VIRONYENTAL HEALTH DIVISIODt P 0 BOAC 2009, STOCKTON, CA 952 (209) 468-3447 RERMIX..EXPIRES 1 YEAR FRQ9 DATE ISSUID (Complete in Triplicate) Application is hereby wade to Sac Joaquin County for a perait to construct and/or install the work bereln described. This application is made in carrpliance with San Joaquin County Ordinance No. 569 and 1862 and t e s and Regulations of San � Joaquin County Public Health Services. /-3;7 O 7s7 Cl Jab Address 140 gest Harding Avenue City Stockton Lot Site/Aereage .25 owner a Nam Rawlison Reade Address 40 Roble Court, Berkeley Phone Contract« Pierson DrillingAddress PO Box 4931, Modesto License No.521617 Phone TYPE OF WELL/PUMP: NEW WELL 95 WELL REPLACEMENT Q DESTRUCTION O Out or Service Well 0 PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well DISTANCE TO NEAREST: SgPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE of WELL PROBLEM AREA CONSTRUCTION SPECIFICATI0 ,. In Industrial O Open Bottom O Manteca Dia. of WeN Exuviation 0Dia. of Well Casing 211 ID U Domestic/Ptivste O Gravel Pack D Tracy Type of Casing Specifications C] Public IX Other D Delta Depth of Grow Seal Type of Grow Neat Cement a 1160stlon —Appron. Depth O Eastern Suffice Soul Installed by Repair Work Done 0 Type of Pump H.P. ate Work Done Well Destruction O WON Diameter Sealing Material i Depth Bentonite Fillets Other x Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW-INSTALLATION 13 REPAIR/ADDITION CI DESTRUCTION U (No septic system permitted if public swWwr is available within 200 loot.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soli to a depth of 1 test: Water table depth SEPTIC TANK. O Typo/Mig Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line" ' LEACHING LINE Q No. 6 Length of lines Total length/size FILTER BED 0 Distance to neatest: Wal Foundation Property Line SEP a SEEPAGE PITS 1 i Depth Site Number 9COUNTY �! SUMPS LI Distance to nearest: Well Foundation Property Line --PUBtle HEALTH SERVICES DISPOSAL PONOS 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 Son Joaquin County Home owner at ficonsed agent's signature certifies the following: "I certify that M the performance of the work for which this permit is issued. I shall not employ arty person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature cenifies the following:"I certify that in the performenee of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion taws of CaHfornla." The applicant MA call for all J re 4ad ins t omplete drawing on reverse side. Signed x 1�._...� Title: p.President Dot,: September 9, 1992 FOR DEPARTMENT USE ONLY / A 3/ Application Accepted by Date ` ` ` Area��__ Pit or Grout Inspection DYDate.L:(��Z Final Inspection by Date L � Additional Comments: Apylicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HB H 31RVICES ' ENVIRONMENTAL HEALTH DIVI3I0H PERMIT/SERVICES 443 H SAN JOAQUIN, P O BOX 2000, 3TOCKTON, CA 05201 INFO AMOV/N�T�OUE M40UNT REM►TTEO 5H 1RECt1VED !Y GATE ►ERMIT NO. itY14tRN.lf�el � Kyr 7t.ae IIIIIILYYYYV/ V!