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APPLICATION SAN uoAQUIN COUNTY PUBLIC HEALTH __;RVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN , PHONE (209)468-3420 P 0 BOX 2009 , STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplica-�e) Application is hereby made to Sam Joaquin County for a per='t to construct ardicr instal' the work herein described. ':his application is made in coo>plie.nce with San Joaquin County Ordinance No. :1i9 and 1E62 and the Rules and Regulations of San Joaquin County Public Health /Services. GSY'We rZ(// ,/0 �- l /U!d✓ �1� i/ �� kt�A �°Kifjy'lyl 1 +/I/St)C;tv slzeiAcreage 73-7Jo0 Address G'GYJ� /��n /�/1 O �1 /�� y�, Owner's Name 6111 V«�1 �" 'r '�/ �� Address LIE t dell, tnC(�kd, �"'cygyy , Phone / ? l Contractor lfk �l� ��' Address J��9 �n�i✓�td /�f'r�Au""�_ e�d, e Ne.30'291-CfZ Phone �a�l'✓ S- 0 °J2 TYPE Or WELL%PUMP: V NEW WELL C WELL REPLACEMENT 7, DESTRUCTION _. Out of Service We!! PUMP INSTALLATION Z_ SYSTEM REPAIR Z OTHER Z Monitoring Well l DISTANCE TO NEAREST: SEPTIC TANK T� SEWER LINES _1A111-,,�.— DISPOSAL FLD. N (MW -7 9 PROP. LINE SJ FOUNDATION N AGRICULTURE WELL q�_ OTHER WELL27s PITS/SUMPS ,&Z- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p i Industrial C Open Bottom G Manteca Dia. of Well Excavation- 41) Dia. of Weil Casing - C. Domestic/Private SR Gravel Pack 7,Tracy Type of Casing_ P Specifications I"1 Public Other i Delta Depth of Grout Seal 4�) 3 O Type of Grout �-LL �,l�By O1 ✓Ii�r I Irrigation lzi�Approx. Depth I I Eastern Surface Seal Installed by N Repair Work Done a Type of Pump H.P. State Work Done _ Well Destruction L Well Diameter Sea=/ng Misterial i Depth Depth Filler Materi s.1 i Depth —r TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION DESTRUCTION i : (No septic system permitted if public sewer is ` available within 200 feet.) lJ�\ Installation will serve: Residence _ Commercial _ Other r� Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK G Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ M�pcfiGti�Olels ^� Distance to nearest: Well Foundation Property i LEACHING LINE No. E Length of lines Totat length/size;" FILTER BED O Distance to nearest: Well Foundation Property SEEPAGE PITS I Depth Size Numner SUMPS LI Distance to nearest: well Foundation PtopertywLine \�(` DISPOSAL PONDS C I hereby certity that I have prepared this apoticanon 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 n such man r as to beCAme subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies to "i "rttfy the rlormancs of the work for vvnich this permit s issued. I snail ampioy persons subject to workman's compensa tion Is X10; is The a pl for r spections. Complete drawing on reverse side. Signe Title: Project Manager Data: July 1, 1992 ar S. Doc um, C,E.G. FOR DEPARTMENT USE ONLY Application Accepted by Date —` v Area 3f Y Pit or Grout Inspection by /�l� Z ;L'1 Final Inspection by Dau/ ®Additional Comments: "✓ `r � Applicant - Return all copies to: San Joaquin County Public Health Services (U 1 L + {� Environmental Health Permlc/Services J �U 445 N San Joaquin, P C Bax 2009, Stkn, :A 95^_01 FEE AMOUNT DUE AMOUNT REMITTEC CASH RECEIVED BY CATE vERMiI NO. INFO �/7n Er t .24 iREV. 4 fH t .� �-'6 V U D��✓/ / �( (..� ' /� ✓`i�