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SAN JOACITYIN COUNTY PUBLIC HEALTH SERVICES i �RONMENTAL HEALTH DIVISION 445 NMN JOAQUIN, PHONE (209)4680W0 P O BOX 2009, STOCKTON, CA 95201 APR PERMIT EXPIRES 1 YEAR FROM DATE I SSUED SAN JOA 2 19,9.3 (Complete in Triplicate) fN�IROLICH�QL�NgC�d�UArp}, Application is hereby made.to Sen Joaquin County for a permit to construct and/or install the v�rUASf9y bed.- This application is made in co®pliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rule s and Ae �>�p��t«tiffr�nn Joaquin County Public Health Services. Job Address 1 Sd1lray _ City —,- Lot Size/Acreage ~ Owner's Name G� Address Phone 7—!o } it�S7- Con IFaClor Address , License No. . Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION^Out of Service Well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL, FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z, i {.-] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing__j> 4 Specifications Type of Grout " I'l Public )A Other R1 Delta Depth of Grout Seat I I IuiUation P - _ Approx. Depth I I Eastern Surface Seai installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Sealing Material & Depth 1AC_!A _6 Well Destruction 10 Well Diameter ?Z Depth Filler Material & Depth �� TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitled it pubfic sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of *all to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity .No. Compartments PKG. TREATMENT PLT. ID Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L-I No. 8 Length of lines Total length/size FILTER BED LT Distance to nearest: Well Foundation Property Line i. SEEPAGE PITS 11 Depth Size Number t SUMPS l_1 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: '9 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 applica ust call for all required inspections. Complete drawing onreverseside. a .5igned X • Title: \r '`� , Data: i 'i FOR DEPARTMENT USE ONLY - CApplication Accepted by Date _9 Area Pit or Grout inspection by Date Final Inspection by Data of to - i Additions ommentr. dw C Appl anurn c ie Jo qui un E d Heath Servic s . f Environmental 1[ealth Permit/8erv7ces 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ?j'J INFO -7- ��-yr�7 ''71 J1 n/ j EH 13 24 rREV.ti�,5� �D ,W i vv l L/J - 1 EH 142E