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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` ENVIRONMENTAL HEALTH DIVISION " '445 N SAN JOAQUIN, PHONE (209)468-3420 lr � P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (Complete in Triplicate) Application Is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application 1s made in compliance frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of,San Joaquin County Public Health Services. //�� Job Address �?6 e--c 4CT�� -_.�� Cit Lot Size/Acreage Owner's Name *WblG LO Ea11--kA ` Address -3�2�)�� Contractor lL�I"# I Address ll q 41 6r,p r -J License Ne�_].SS:S/ Ph on 12-lfzlf TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES <4W DISPOSAL FLD.� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL '�PROBLEMAREA CONSTRUCTION SPECiFICL1TION5^' - -� - ��"� _-�Y �"'� R Industrial O Open Bottom- ❑ Manteca Dia. of Well Excavation Dia. Dia. of Well Casing C.l Domestic/Private bkg4ravet Pack - 11 Tracy Type of Casing-P[C Specifications P f�l Public is OthF fj� / (l Delta Depth of Grout Seal -�� f Type of Grout *irrigation ,n pprAe1pth I I Eastern Surface Seal Installed by///� ��f A. ILtir \\`� Repair Work Done ❑ Type of Pump H.P. State Work Done - Well Destruction' ❑ Well Diameter y f Sealing Material & Depth Depth Filler Material & Depth t\VVV i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number sof bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg. 't Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line } LEACHING LINE Cl No. & Lengthi of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line '1 SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance tonearest: Well Foundation Property Line DJSP05AL_PONDS ,,.❑ 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, 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 shelf 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 cartify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion taws of California." The applicantsr usl call rfnor�alll required inspections. Complete drawing onn reverse side. SignedX— i�f c. rL'1A AGK] _ Title: L,KLLLetf . ............ .._.,.._._.___ Date: /01-Z_1q - 1 0 / FOR DEPARTMENT USE ONLY r6 (�`4 Application Accepted by �/�/� �/j/� Date / - Area Pita Grout I apection by Date/® �S vajaal Inspection by ` Data Additional Comments. T Q 8 1992 Applicant i,- Return all copies to: San Joaquin County Public Health Sery s j Environmental Health Permit/Services 445 N San Joaquin, P O Box 2008, S j ,w; OQ1 COUNTY INFO AMOUNT DUE AMOUNT REMITTED CASH mn §YwEU I AL*,tt'W dl Ii_ifiM17'NO. i . EH13-241REV,i/A5i 4W, jj;pt�/JfO EH 74.26 i