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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �Jell �O. ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,` PHONE (209)468- (�T]1;(�in� ,•^� P 0 BOX 2009, STOCKTON, CA 9520 L�LI O l f PERMIT EXPIRES 1 YEAR FROM DATE ISS <� (Complete in Triplicate) 24 1992 Application In hereby made to San Joaquin County for a permit to construct and/or in t g.-wo-rk herein described. This application in made in ccupliance with Ban Joaquin County Ordinance No. 549 and 1862�I WTA;Is1HWTMtions of San Joaquin County Public Health Services. PERMIT/SERVICES �� Job Address vlT� �. ,S��.�� e_vCity Lot Size/Acreage V I 2 Owner's Name slW12sf/.► � eyl Af'(- Cn Address to rsQx �J r��IPenn CAI �5 `Phone S91 Contractor AddressNFLkn. 64, boo I 3`) Phone .2,44A7(_)3 tv��icense No. � � TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT LI DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATIO �J SYSTEMREPAIRLl OT ER ❑ Monitto�orr�inng��Wi 1 C.1 - VOT NCE TO NEARS : SEPTIC TANK � SEWER LINES � DISPOSAL FLO.� PROP. LINE 2 . FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ .1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS eq-Industrial O Open Bottom ❑ Manteca Dia. of Well ExcavationI ti C_t N Dia. of Well Casing 3 on, f.l Domestic/Private RI Gravel Pack7 O Tracy Type of Casing Yni Specifications"Z IV1C-11 I'1 Public 1:1 Other F1 Delta Depth of Grout Seal"' �� e.�- Type of Grout fle'i TiQwte.+ I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ 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.) Installation will serve: Residence T 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 LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 workman's compensa- tion laws of California." The applicant ust call folpall lrrequire�d innssPections. Complete drawing on reverse side. Signed XTitle: �t�� Date: / Z_ 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 to: San Joaquin County Public Ifealth Services Environmental Ifelklth Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO EH 13-241AEV.iie5) EH 14.24