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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 ��1 P O BOX 2009, STOCKTON, CA 95201 PAY ��. RECEIE�FN PERMIT MWIRES 1 YEAR FROM DATE ISSUED APR 16 1993 y �; �� Omplete in Triplicate) SAN,10ftiijy � PUBLIC Iq r G COUNTY A 1 ca�lo is ereby made to en Joaqui Dunt for permit to construct and/or install tfi�1 Q ' rSi �{; is II application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules Joaquin County public Health Services. Ni Job Address aCity v Lot Size/Acreage Owner's Name r` AV l 1^/79 Address __ Ia J I /Poallal. fir- Phone s r 7 r �p �r2.ty1v X5.3 Contractor U + �� Y%ep,4�dfess `hr a License No, S Phone TYPE OF WELL/PUMP: NEW WELL Q WELL REPL CEMENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -- - FOUNDATIONS �`�IAGRICULTURE WELL rOTHER WELL f� mf_87sUMP5— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Ria. of Welt Excavation pia. of Well Casing s Ca Domestic/Private 0 Gravel Pack 1444acy Type of Casing_ Specifications ! I'I Public 1-1 Other ! rl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I 1 iEastern Surfa a Seal Installed by Repair Work Done 1�11 Type of Pump H.P. State Work Done_ �- Well Destruction ❑ Well Diameter It, Sealing Material & Depth (� Depth 0 Filler Material & Depth l V1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I lNo septic system permitted it public sewer is VJ 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: I Water table depth SEPTIC TANK. ❑ Type/Mfg ! Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line s LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth t Size Number _SUMPS LI Distance to nearest: Well Foundation Property Line "D`I5'FO_9_A_L-PDNDS' -Cl' Cl 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 shalt not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certity that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." J The applicantmu call for all r uired pections. Complete drawing on reverse side. Signed f sTitle: _�� ` �" _ Date: FO EPART T US NLY f r Applicstion Accepted by Date a / Pit or Grout inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies,to: San Joaquin County Public Health Services I Environmental Health Permit/Services � 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEp RECEIVED BY DATE PERMIT'NO. INFO FEE ` n • EH1 .21(REV.sins) •yV D� �� / `.. p"70 ��j�t EH 11.10