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APPLICATION SANOAQUIN COUNTY PUBLIC HEALTH RVICES PAYMENT ENVIRONMENTAL HEALTH DIVISION OVE� 445 N SAN JOAQUIN, PHONE (209)468-3420 �EC 1 19 �v P 0 BOX 2009, STOCKTON, CA 95201 CNI ES PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SPOCO QPjNOSNpIV\SIGN (Complete in Triplicate) ppppp��T e�ba`Ys hereby Slade,to Sm Joaquln County for a permlt to construct and/or install the work herein described. This fd)1j41catian Se made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. JCO 1 t111rad City Tat 700+ 1Lot Size/Acreage� Job Addres 2Q92- owner's Name EM Siarpe Debt Address loth RoadTHtlj2L) Phone - Contractor t2tiID Address 2825 E. Malls StOdtttm __ License No. 512268 Phone 209-45-8M TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out or Monitoring Well -- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ IN DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES Tki!]D n DISPOSAL FLO.NlA PROP. LINE tl90' FOUNDATION ± 2T AGRICULTURE WELL + 511' OTHER WELL PITS/SUMPS i'�r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10 Oia. of Well Casing P6T� ( Type of Casing- Domestic/Private ❑ Gravel Pack ❑Tracy 9- Specifications I'I Public LY Other n Delta Depth of Grout Seal 15' Type of Grout I I Irrigation ."CL Approx. Depth I 1 Eastern Surface Seal Installed by 4=111 IM - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Diameter Sealing Material & Depth Well Destruction Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I availablerc system w thin 200 last.) it public anwer is Installation will serve: Residence_ Commercial _ Other Number of living units: _ Number of bedrooms Water table depth Character of wil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lina SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 comp ena- tion laws of California." The appi!5c n must all for all r ui on . mplete drawing on reverse side. ` �� _( PrESICIEnt Date: 10/17/93 Signed it Title: FOR DEPARTMENT USE ONLY // 5 Date ! Area Application AccsOtY�e//db 41'l Pit or Grout Inspection ate Final Inspection by Dats Ex/ mw Abe Additional Comments: Applicant - Reurn copies to: San Joaquin County FUbii& Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Still CA 95201 FEE gMOUNT OUE AMOUNT REMITTED CASH RECEIVED BV GATPERMIT NO. Page I3� INFO 3L{ ` h • EN IY711fl EV.1/n51 ? `f es =6 "79-3 i3 EH ib]a