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SAN JUIN COUNTY PUBLIC HEALTH SICES , t V I RONMENTAL HEALTH D I V I S I O T H —P5 445 N SAN JOAQUIN, PHONE (209)468-3420 `L) P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) P.nd Application is hereby made to San Joaquin County for a permit to construct and/ore work/,� ascribed. This application ie made in compllnnce with Ban Joaquin County Ordinance No. 549 and 18 Rules and latione of San Joaquin County Public Health Services. S. S-J,• L MAR 2 1992 Job Address /� g C.,r�F� L City�jf� 1 __ Lot Size Acres e�x:� Owner's NameI_►+' '1 t' _ Address P�1S ox 7S-7,4R,i+ OVIM1I/6' LW�1 Contr3ctorLAN/f1Cl1CT_aVAddressZODk t License NoS-3944—_PhoneZ44a1-4>3 TYPE OF WELL/PUMP: NEW WELL tZ, WELL REPLACEMENT (-1 DESTRUCTION Ll Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER El 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 I. Pte- 3 114-Industrial O Open Bottom O Manteca Dia. of Well Excavation k Dia. of Well Casing Cl Domestic/Private Gravel Pack O Tracy Type of Casing_P Specifications-Scyt 40 1'1 Public FI Other (I Delta Depth of Grout Seal �i� COQ *rr-� Type of Grout vti I I Irrigation 34-[2_ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Residence— Commercial_ Other `J Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: --Water table depth G/ SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line tram— LEACHING LINE 0 No. & Length of lines Total length/size P4 IN FILTER BED ❑ Distance to nearest: Well Foundation Property Line VEP AR 4 i992 SEEPAGE PITS 11 Depth Size __ Number S/iN rp�oblN SUMPS LI Distance to nearest: Well Foundation Property Line PU ^^11 COUNTY DISPOSAL PONDS ❑ E VI{-�N�ALLTH SERVICI S 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, an 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 call for Ireuir�pections. Complete drawing on reverse side. / Signed X Title: � il— ,2� 7 L Date: F PARTMENT USE ONLY Application Accepted by -CA-1 �k S� Date %^a-y 2 Area C) Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT OUE AMOUNT REMITTED CASHK INFO `CRECEIVED By DATE ^ PERMIT'NO. EH 1324• EH11.NIREV.Iin51pA V 0 � `.' lr � C7Z� � �• r� l _ iCS {i' U