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RESNA , SACRAMENTO TEL : 916-852-6688 Oct 05 '92 10 :52 No .007 P . 15 APPLICATION 1-4-08 _0l i SAN J'OAQUIN COUNTY PUBLIC HEALTH SEHvIGES MWIRONMENTAL HEALTH DIVISION PAYkIENT 445 N SAN JOAQUIN, PHONE (209)468-3420 {� P O BOX 2009, STOCKTON, CA 95201. RECEI'V`ED .SIT FaP z RES I YEA .FPATE =U OCT 2 6 1992 c AN.0� t)IN COUNTY PUP-€C HEALTH SERVEC PS Application is hereby made,to San Joaquin County for .a permit to construct andlor irsa �tth� d" kP'iy "rkiiidea - tile` �( to apPllcatioo is made in compliance with Ban Joaquin County Ordirtattae so. 549 and 1862 end the Rules and Regulation or Ssa Jasquin county Public Health 8srvii:s. 1 Job Address l bSoo So..m S 'S rrT Lov tsar r*v� city,Ly}Ty,I it A Lot Size/Acreage J(of2oc Ao.#rH C4 TNr%K Ps440_w94Y SL.Pit4r3to Owner's Name g IL [..a"rP A-NY Address %W f i-A4 8 Phan 0 �l Z 9, 90��"x� C�4. S �c y�390 -ra-GBg��1.3 contractor ! A4drtSS License No. _ Phone TYRE OF:WELLIPUMP: NEW,WELL © WELL REPLACEM€NT M DESTRUCTION 0 Out of service well r= PUMP INSTALtJ1TION SYSTEM REPAIR C7 OT ER Q Monitoring 41e11 DISTANCE TO NEARES*; SEPTIC TANK r SEWER LINES 7 -"� DISPOSAL FLO. PROP. LINE FOUNDATION{,! AGRICULTUSE WELL M OTHER WELL PITS/SUMPS P"A INTENDED USE TYPE OF WELL PROBLEM AAAA CONSTRUCTION SPECIFICATIONS _ 0 industrial It rr D span eottam D Manteca Dia, of Wail Excavation B Dia. of Wall Caging 2 i C.1 Domestic/Private 0 Gravel Pack Q Tracy Two of Casing_-, rV6 __ g ;t;catiGH Ito VI Public I:7 0 her f1 Delta Depth of Grout Seal *�_Lb Type of GroutFewffNrlBlsl~f'raAare 4 I ttrtUeuon Appfora. Dolph I I Eastern Surfao0 $0411 Installed by 7�R SLV W . 3 .; (� Repair Work Done 0 Type of Pump �1_._-- -. H.P. State Work,Done — CS Well Destruction ❑ Well Diameter 'I .- -� Sealing Material & Depth M111eklk iz 0 Depth + Tiaer blaurls l i Depth mai te� %40 TYRE OF SEPTIC WDRK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I IN*septrc ayaam permitted if public sewer it V ' avaiiab{e within 204 feet) `l 1 Installation will serve: Residence_,r,,, tommercial_ other Number of living units., _ Number i of bedrooms i Character of salt to a depth of 3 flet; `! Water tabic depth_ SEPTIC TANK 0 Type/Mfg I t Capacity,,,,_,^, No. Cornpattmenta EKG. TREATMENT PLT. 0 F Method of 040sal Distance to lamest: Well --_ .. FoundationPro e i p rty Lone ,r LEACHING LINE 0 No, & Length lgf linea Total t0nglhlsize FfLTER $ED Q Distance to nearest Well Foundation _ ,_ Property Line — SEEPAGE PITS I I depth I Si:e Number SUMPS Lt Distance to noirest: Well ,� -- Foundation Property Line u DISPOSAL PONDS ❑ i 1 heraby certify that I have prepared this appikattan And that the work will be done in accordance with San Joaquin county ordinanCea, State laws. enc g fules Arid regulations of the San Joagvin Cc I ty Home OwnOr Or onlicensed Irl Aun su agem's signature carotica It"following: "I certify that in the D000rmanoe of the work for which this permit is issued,f&hall not employ any person ch manner as to became subject to workman's Compensation laws of California," C6111raet6r'6 hiring or sub-contracting signstwe certifies the following: ''I certify that in the performance of the work for which this permit is iasuee,I Shell employ persons subject to workman's Compania- tion lawn of California." The eoplicant mu req ms ctions, Complete drawing an reverse side. �} Signed X '�� l . sate: {� DEPARTMENT USE ONLY Application Accepted by Data Aa Pit or Grout tnsptctipn by to final tnsp0ction by date Gy Additional Comments; L t Applicant - Return all capias to: Baa Jnaquta County Public Health &ervices a Enviroamerttal ltoalth Permitlaervicea 445 N z' Joaquin, P O Box 2408,' Stkn, CA 95201 FEE AMOUNT OUR AMOUNT REMifteo RECt{yEp$Y 4NFq K ASH t}ATE PtiltrVtlT'n40,