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J <br /> u' U SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONILENTAL HEALTH DIVISION <br /> MAR 29 1992 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> AM-w EST <br /> FILE# P O BOX 2009 , STOCKTON, CA 95201 <br /> UT CREEK,CA pER![IT EXPIRES I YEAR FROM DATE ISSUFM <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 51s9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ` J <br /> ' Z i2 5� w20� e �Gr✓1 K* Z city 5 `�'� Lot Size/Acreage u G'� <br /> Jots Address _i <br /> Owner a Name C-0 M 40t Add►ess ] <br /> ��LJYLSS 1.^4 <br /> V �lo� _ Phone '7�a <br /> Contractor G- 'O,v► Address 10CM License N - <br /> hone 67 1 <br /> TYPE OF WELLIPUMp NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION U Out of Service Well cl <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER X, 14cmitaring Well 9, <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES !1 16 — DISPOSAL FLO PROP LINE <br /> FOUNDATION --uL— AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> INTENDED USE Zit ��t <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia of WaG Casing <br /> t-1 Domestic/Private AGrevel Pack 1J Tracy Type of Casing 5L,{4 AQ — Specifications <br /> I 1 Public i"1 Other n Dolts Depth of Grout Ssal <br /> Type of Grout <br /> 1 1 Irropatron JX0A q,'6l+ Appro■ Depth Kliastem Surface Seat Installed by <br /> Repair Work Done U %of Pump HIP State Work Done <br />' Well Destruction l7 Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I l sdsbpe c syftst �O f�tt'ed it public setiver u <br /> Installation will some Residence— Commercial_ Other <br /> Number of living unit$ Number of bedrooms <br /> Charaof sod to a depth of 3 feet Water table depth <br /> cter <br /> SEPTIC TANK ❑ Type/Mfg Capacity MW . <br /> PKG TREATMENT PLT C3Distanceto nearest Weil Foundation Property <br /> LEACHING LINE 0 No & Length of lines Total length <br /> FILTER BED 0 Distance to nearest Wall Foundation Prp1Ji9x1L1rAr.6 TSP-^,`,'MES <br /> i ( O N <br /> 1 SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this appitcsuon and that the work will be done in accordance with San Joaquin county ordinances, stair laws and <br />' rules and regulations of the San Joaquin County <br /> Home owner or licensed agent$signature certifies the following "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California ' Contractors hiring or sub-contracting signature <br /> certifies the folowong "I candy that tit the performance of the work for which this permit is issued,i$heli employ persons subject to workman s compensa <br />' tion laws of California" <br /> The applicant If r r ctions Complete drawing on reverse sole <br /> Signed <br /> Title — Date <br />' FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Dots Artist �l <br /> Pit or Grout Inspection by Data Final inspection by Dam--� <br /> Additional Comments <br /> Applicant - Return all copies to San Joaquin County Public Health Services / <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 o I } <br /> FEE DU AMOUNT DUE AMOUNT REMITTED t CASH�j RECEIVED 6Y DATE Q PERMIT NO <br /> INFO +' (►f v 1�a ✓ /J ! a7' /�/� Qa.�l� <br /> • EM 13-24 111[V ai <br /> EM 14 26 J <br />