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-�� SAN JWUIN COUNTY PUBLIC HEALTHVICES VIRONMENTAL HEALTH DIVISI 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EgPIRES 1 YEAR FROM DATE IS (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install t p k4he'H92described. This application in made in coatplinnce with San Joaquin County Ordinance No. 549 and 1862 an =1 s and Regulations of San Joaquin County Public Health Services. ^ Job Address g4), S. s�k�ln Ny City� 1 _ PERMI w�I�� Owner's Name > (Address rLd� s1�1_ CA T53 S2_ hone i)�o 424 �T a r Contractor ddress �e C��b4�e No. q�_(�Pn6�e.Z �'1�1e3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well lc,�f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE J^l FOUNDATION AGRICULTURE WELL OTHER WELL C _ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS,' 5 — GL- rt&VCe 3 Industrial O Open Bottom El Manteca Dia. of Well Excavation 7=.1f LnC Dia. of Well Casing aasing �� [I Domestic/Private )0 Gravel Pack O Tracy Type of Casing LhQ�.p�� rr__ Specifications " 4 I'I Public Ll Other r_1 Delta Depth of Grout Seal jqlpACDA �Q�Jket Type of GroutWA.J-C,PKILI-A r I I Irrigation c;L5D Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth ^�J Depth Filler Material i Depth 4� .v TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if priblic sewer is available within 200 lest.) Installation will serve: Residence_ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line D Ay■■s-.._.�r LEACHING LINE CI No. b Length of lines Total length/size_ '�� N FILTER BED O Distance to nearest: Well Foundation Property Line ncCI V�=1,J MAR 4 199-2 SEEPAGE PITS 11 Depth Size Number _ N CO[JN FY SUMPS LI Distance to nearest: Well Foundation Property Line PI]RI IC. HEALTH SERVICES DISPOSAL PONDS ❑ ENVIRONMENTAL HEALTH LIV sI rt1 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 workmen's compensa- tion laws of California." The applicant must �call�lt r uire lV tions. Complete drawing on reverse side. �y� /p 7 Signed X�� .-�./�T/�/ Title: y'`� ��v!-!C Date: _ RENT USE ONLY Application Accepted by Cw, Date "_21 A-c Z- Area C) Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Ilealth Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO ((AMOUNT DUE AMOUNT REMIT-TED ` CASA CK RECEIVED BY DATE PPERM17 NO. EH 13 24 FH 14.2a(REV,iix51 WHYl V V 33 Z� a -Q�.�� lnN` 05f 5