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OCT 91992 APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201. All 'PERMIT E%PIRES X YEAR FROM DATE ISSUID (Complete in 'ell' Application In hereby msde.to San Joaquin County for a permlt to construct and, install the vof�jhgrein,deschbed. This application In made in compliance,vith San Joaquin County Ordinance No. 549 and 1862 and the Rules �!RFguletions rof San Joaquin County Public Health Services. 7 .`�s Job Address 00O G>'J' `Q`��aL.� C,ry Lot Sise/Acreage Owner's Name J�fj��7/y- 1 �� Address _ ! t1'�k `7 �d. �ha +\ Phone :+�'`t''y"�� f' S-11zC.g Phone ,v C6n1130tx Address�8 5• 1- , `� !License No. ; TYPE OF WELL/PUNtP- NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION V Out of Service Well ❑ PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ _.OTJiEA.❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES77 -7- DISPOSAL FLD r 'C PROP. LINE '' / FOUNDATION �iEAGRICULTURE WELL OTHER WELL PITS/SUMPS / ) INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- ❑ Industria! O/Open Bottom Manteca Dia. of Well Excivatgon / Dia. of Well Casing ['.I Domestic I Private (>j Gravel Pack7 0 Tracy Type of Casing_ r Specifications�'ff ('I Public (.I OtherI n Delta Depth of Grout Seal f Type of Grout�m I I IrriUation Approx. Depth I I Eastern Surface Seal Installed by e 1 Repair Work Done L1 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth ` 2 Depth I Tiller Material i Depth !Py—'Y _� •4 1�l TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I INo septic system permitted it public sewer is d available within 200 feet.) Installation will serve: Residence Commercial_. Other c Number of living unite: Number of bedrooms Character of soil to a depth of 3 feet: ( Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ ` t Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. b Length of tines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth -... Sire= ----- _-.Number_ t SUMPS LI Oistance to neatest: Weq Foundation Property Line DISPOSAL PONDS ❑ 1 I hereby certify that 1 have prepared this application and that the work willbe done In accordance with San Joaquin county ordinances, state 7shall , an 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. not employ any person in such manner as to become sub)ect to workman's compensation laws of California.-Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, t&hall employ persons subject to workman'&eompenss- tion laws of C rnIs.•. The applic ni mu t call for all recLuiraid in Qec ons. Complete drawing on reverse side. ssd Title: ✓ Date: Z' L l FOR DEPARTMENT USE ONLY / 9 ' Application Accepted by ' Date �` Z Area Pit or Grout Inspection byDate Final Inspection by Data Z Additional Comments: / Applicant - Return all•'copi0s to: ban Joaquin County Public Health Services t Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 �I�FEE AMOUNT/DUE AMOUNT REMMirr ED CAS,, RECEIVED BY / DATE PERMIT"NO. • EM 1321 IREV. •al /!! EK tr-ab