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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES GRECEIVED ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 J U N 19 1992 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Ser ices. A4 c JobAddres y City W Lot Size/Acreage C��- Owner's Name Address a LVo2_ Phone Contractor a Address/ ,0oRosea? License No Phone � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION LI Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTfNDED,uSE-- __ TYPE OF WELL---- PROBLEMAREA -CONSTRUCTION-SPEGIFIGAT40NS---=,�- --- �- - - - - - - - . ❑ Industrial ❑ Open Bottom ❑ Manteca Pia. of Well Excavation Dia. of Well Casing F1 Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing_ Specifications I') Public El Other n Delta Depth of Grout Seal Type of Grout I i Irrigation Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. -9 Stat o(k Don G7sp Well Destruction O Well Diameter Sealing taterial & Depth ��I .S ,1. x`72- ^a^I�Cl�� S7�!1 Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIRIADDITION I I DESTRUCTION i I iNo septic system permitted it 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. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL 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 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 must call for all required ins tions. Complete drawing on reverseode. Signed X O t t/� �- - -- Title: Date: 6 2— OR OR PART T USE ONLY �+ Application Accepted b Date Area `dr- -- Pit or Grout Inspection by Date Final Inspection by Date�yL Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED SH CEIVED BY ATE PERMIT'NO. INFO • EM13-24(REV.I/K el EH 14.21