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SAN 'aUIN COUNTY PUBLIC HEALTH S��T{�y:ICES RECEIVED SIV I RONMENTAL HEALTH D I V I S I`�%' 445 N SAN JOAQUIN, PHONE (209)468-3420 SEP 1 7 1992 P O BOX 2009, STOCKTON,' CA 95201 ENV}RONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED { � �r''t ��i�J (Complete in T3jiplicate) Application is hereby made td',San Joaquin County for a permit to construct and/or install the work herein described. Sans application is made in compliance with San Joaquin Count Ordinance No. 549 and 1862 and the Rules and Regula tions Joaquin County Public Health Services. /4t'i�M A D-- Let Size/Acreage Job Address City S Address S W Phone o z S Owner's Name G RM PO C 4. q S11 D Contractor !J L4 Address .0. Q e X I 1 'b 1 TA-a)Wf icense No.S 6-1 1572-_Phone =�' f � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ OTHER Monitoring well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR C1S v r!. $0 XiAo s-s DISTANCE TO NEAREST: SEPTIC.'TANK _ I SEWER LINES , LSU _'2'n� DISPOSAL FLD.1.� ,PR LINE r12 FOUNDATION AGRICULTURE WELL (1:00 ' OTHER WELL v 0 r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 r w Industrial ❑ Open'Bottom ❑ Manteca Dia. of Well Excavation Dia 'of Well Casing C.1 Domestic/Private ❑ Gravel Pack L3 Tracy Type of Casing_ Specifications 11 Public IN Other $a 11 to✓to)?Delta Depth of Grout Seal Type of Grout r Q MR r✓l_-- I I litigation Approx. Depth I I Eastern Surface Soul Installed by a Repair Work Done U Type of(Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material i Depth Depth Filler Material & Depth - � � TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDITION I 1 DESTRUCTION I 1 INo septic system permitted i1 public sewer is available within 200"feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of sod to a depth of 3 I,feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal + Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 11 Distance to nearest. Well Foundation Property Line t SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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 compensa- tion laws of California." The applicant must caPol all required inspections. Complete drawing on reverse side. v Signed x _.__. Title. wr Date:K Z �FORMENT USE ONLY Y_3 Application Acceptedby Date rea ` Pit or Grout Inspection by Date final Inspection by all Ik - Additional Comments: _ Applicant - Return all copies to: San Joaquin County Public Health Services pJ Environmental Health Permit/Services / )0 pJ Ii, 445 N San'Joaquin, P 0 Boa 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATEPERFAWN0. INFF/OO }/��, CASH EM 1}24(REV.i/As ARV I.'' cx rY�YJ� ..� Z', Z�a� EM 14.26 i I .l