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SAN 4LQUIN COUNTY PUBLIC HEALTHVICES VIRONMENTAL HEALTH DIVISI Sn`j�, 445 N SAN JOAQUIN, PHONE (209)468 Jj u O P O BOX 2009, STOCKTON, CA 952 PERMIT EXPIRES 1 YEAR FROM DATE issUAR 2 4 1992 (Complete in Triplicate) ; �� .�-�yQ,�� Application is hereby made to San Joaquin County for a permit to construct and/or iniU RDNN �NT�eh� iri ��d. This! application Is rade in compliance with San Joaquin County Ordinance No. 549 and 1862 nn�6( �i� {Zl� gulatione of San Joaquin County Public Health SSerlvices. Job Address =L-1 Z,Sojjl 1J7(]c Ave- City - Lot Size/Acreage e 7 Owner's NameslyVI SM 1/fiVC.� Address C06ex 959, ,le0�_G5344i( Phone AMAZ�+ �M l 1411 0�� CgIb) Contractor F ddress [-W 1 7- License No1_Phone 4*'1-103 TYPE OF WELL/PUMP: NEW WELL 9&_ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 � ' V('t 3 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing -1 L�k C I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing}P>-VC a 5<-h 40_ i�" peciltions I'1 Public f.l Otlper,/,� n Delta Depth of Grout Seal ti $ _W ypa of4Grout I I Irrigation cM.Approx. Depth I I Eastern Surface Seal Installed by LAA.,J(r-y Repair Work Done U Type of Pump H.P. State Work Done _ Wel Oe truction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material i Depth TYPE OF SE T C WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line PAY ME NT SEEPAGE PITS 11 Depth Size _ Number VE SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4 1992 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin gAtNtJ®""!CM"1NT*s, and rules and regulations of the San Joaquin County " H A T.H SF_RVICFS Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work f ��II ¢,� , t�C'.3 1►�pt employ any person in such manner as to become subject to workman's compensation laws of California." Contrat�� t ting 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 all required inspections. Complete drawing on reverse sidle.. Signed X,�$(c' /Jl.;/L Title:� J`ST" -7I Z U Date: OR DEPARTMENT USE ONLY Application Accepted by Zr-- _ , [ t`\'\�-c, `. Date �a` Z res O Pitrout nspection by Date iFinal 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 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK f RECEIVED BY DATE PERMIT'N0. • Em 13.24(REV.tiNStWIA, QJC10 \.1O 3/)—� EH t�.2e I`�'� l 40 7 O's 90