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i OSAN JOAQUIN COUNTY, PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE .(209)468-3420 DEC 3 11992 P 0 BOX 2009, STOCKTON,- `CA 95201 PERMIT EXPIRES•1 YEAR- FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate)r. PERMITISERVICES Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This a lication is made in compliance with San Joaquin County Ordinance no. :549 and 1862 and the Rules and Regulationsl-of San PP �,. t Joaquin County Public Health Services.- +l C p r I� ZA7"11 r� Lot Size/Acreage -- l�f /t• �!y�- City Sh Job Address Phone Owner's Name �{ Address _, ^ License No. �- Phone Contractor Address WELL REPLACEMENT ❑ DESTRUCTION mut of ServicelWell TYPE OF WELL/PUMP: NEW WELL ❑ MonitoringiWell � - PUMP INSTALLATION ❑ �-» SYSTEM REPAIR. I.. r _ OTHER ❑ ,II, r SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE'' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS :j _ / Did. of Well Casing �P G7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Weli Excavation Type of Casing- CI asing_ i 1 Other n Delta Depth of Grout Seal Specifications � f-] Domestic/Private ❑ Gravel Pack ❑ Tracy _ _ Type at Grout � 7I'1 Public i W k I Irrigation —.Approx. Depth... I I Eastern - Surface Seal Installed by y� Repair Work Done L7 Type of Pump H.P. State Work Done t Sealing Material & Depth Well Destruction O Well Diameter Filler Material 6 Depth II Depth i TYPE OF SEIRIC WORK: NEW INSTALLATION I 1 R€PAIRIADDITION i I DESTRUCTION I I (No septic system permitted if public rawer is ((�� __available within 200 feet.I J� Installation will serve: Residence Commercial_' Other Number of living units: Number of bedrooms Water table depth Character of sail to a depth of 3 teat: SEPTIC TANK 13 TypelMfg Capacity No. Compartments _ PKG. TREATMENT PLT.❑ Method of Disposal i .'Distance to nearest:a Well -Foundation Property Line ` y • r 6" LEACHING LINE ❑ No. & Length of lines Total length/size ;I u FILTER BED ..' n -Distance to nearest:_-r Wall r - Foundation Property Line _SEEPAGE PITS t 1 Depth Size Nu Thar L SUMPS LI Distance to nearest: Well foundation Property Line !� f DISPOSAL PONDS. ❑ " I hereby certify that I have prepared this application and that the work wi11 be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin County.,, -- « - I e ° Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is iss�ld, I shall not Hopley any person in such manner as[a become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature M� certifies the following: "I certify that in the performance of the work for which this permit is farmed, I shall employ persons subject to workman's campensa cion laws of California." The applicant at call for all requ' inspections. Complete drawing on reverser side. 1 J Signed Title: I/ r Date: " r OR D A T USE ONLY r Application Accepted by Date res ` Pit or Grout Inspection by Date Final Inspection byDate 4 x I .111I _Ire 111 7 115111 Is: �/i �.�� A�plieant - Return all pies o: San Joaqu n Co my u is Health Services Environmental Health Permit/Services I 445 N San-Joaquin, P O Box 2009, Stkn, CA 95201 II t FEE .AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY ATE PERMIT NO.�� - ` t - INFO e 9 J/pJ (moi + EH 13.24 tREV.t/Ns) UN) ©'�' / �� ''/ o- �� { ' i EH 14.25 t _ r- it i