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vJ e-,\\ (o SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ^` ENVIRONMENTAL HEALTH DIVISIONr 445 N SAN JOAQUIN, PHONE (209)468-3i7� o P O BOX 2009, STOCKTON, CA 95201 JJ11 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEU (Complete in Triplicate) MAR 2 4 1992 Is hereby made.to San Joaquin County for a permit to construct and/or ins ta ��,�t described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 an '`�frit�} Joaquin County Public Health Services. �SE ACE ne of San Job Address CityA`f"�— Lot Size/Acreage .50x_ me,10 Of,:�Z� Owner's Name lw►p Son PA t0 < < +IPT fI✓t� Address 0,0.A1)2i 7S C r k1ran r CA 95301 Phon - 441 �.v tcl I\. �Address ( C �} -7 C'31 O L4Q 91 03 Contractor V License No.�� r Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION C1 Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR O , f�OTHER O Monitoringell U DISTANCE TO NEAREST: SEPTIC TANK -AZA SEWER LINES Z 500 _ DISPOSAL FLD1� PROP. LINE-L,5 2 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; <-,-,e roe re- 3 K Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing IL-1/4-t-c-k C l Domestic/Private El Gravel Pack ❑ Tracy Type of Casing M Specifications !4' t"Kle,W111 j 11 Public f7 Other n Delta Depth of Grout Seal'- Type of GroutV16(A-C(1-10r4-- I I Irrigation g ZOG?�Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material Z Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line J A VMc SEEPAGE PITS 11 Depth Size _ Number VeD SUMPS LI Distance to nearest: Well Foundation Property Line_ NJ 2 (i 198 DISPOSAL PONDS ❑ 0 JJ I hereby certify that I have prepared this application and that the work will be done in accordance with San "may t R��n f jj{OlJ)ews, and rules and regulations of the San Joaquin County TA( d�F'�VIL` r Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this perU�'hJ�s , all not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting 1 libture tion l es the following: "I certify that in the performance o1 the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lawn of Calito►nla." The applican ust call f r all requ'ed inspections. Complete drawing on reverse side. Signed X l t Title: ��f� Date: , FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies tb: San Joaquin County Public Health Services EnvironmentalVllealth Permit/Services 445 N San Joagbin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT'NO. • EM 1324(REV.tins) N 1t-2e