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APPLICATION 7— SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 3; 6D ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 y 3�• '® �`� P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby mads to San Joaquin County for a permit to construct and/or install the vork 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 Services. L o-� c/ Re c o id Job Address N Z()5 // 474 q-4,144 City - ii k.g Lot Size/Acreage Owner's Name Rowland fabzc-to.fh- Address Aa ma Phone 952-2963 Contractor C-P_a zk b ei-L, Iae Address 2024 C• Cha�.te,, License No'r 77 560 Phone TYPE OF WELL/PUMP: NEW WELL ®x WELL REPLACEMENT [ 1 DESTRUCTION ❑ Out of Service We11x® PUMP INSTALLATIOW® SYSTEM REPAIR 0 OTHER O Monitoring Well ❑ *. DISTANCE TO NEAREST: SEPTIC TANK f 5OSEWER LINES DISPOSAL FLD,, F f PROP. LINE + 15 ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I;)" Dia. of Well Casingb" xT�XDomestic/Private XAfRZravel Pack 0 Tracy Type of Casing_P VC Specifications 7 6 ['I Public [.1_ether fl Delta Depth of Grout Seal 10 0 ' Type of Grout L I I Irrioation _ Approx. Depth I ) Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump Slj-ff____ H.P. 7 j'/�_ State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth '1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments [� PKG. TREATMENT PLT. Gl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS [ 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS 0 1 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 of 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 applica call r It ir� in s ete drawing on reverse side. Signed x Title:VP .C-ea zk Ue-Q-Q, Inc pate: 22 �z-,-fg--22-r fRDEPARTMENT USE ONLY , 4 ta Application Accepted by Date Area Pit or Grout Inspection by W ate '2:�'92- Final Inspection by �yDate Additional Comments: Applicant - Return a opies to: San JoagCounty Public ealth Services • ��Cttd ��` 1�� Environmental Health Permit/Services (lQ�j S r 0 445 N San Joaquin, P O Box 2009, Stkn, CA 95201q,5I `` �i INFE AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. MCI. EH 19-24 1REV.sixsl 1 G c o �4H`1J �2 el 12—' Z�, EH 112e i �. Q7, 3