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OST 9 1992 ` APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 ' P O BOX 2009, STOCKTON, CA 95201 ^a PERMIT EXPIRES I YEAR FROM DATE ISSUID fete in "_'_ ^ ) PU-1 ':I'g, (Cam p —r- �_ �3i�'.. • !t• � �••l� 1I;.r Application is hereby made,to San Joaquin County for a-permit to construct and/or install the vorl /ktrrein,desc Lb�d. This � application is made in compliance;vith San Joaquin County Ordinance No. 549 and 1862 and the Rules L#e;gul�`fbsii of San Joaquin County Public Health Services. /}Ct � Job Address �O� � """"`��" City Lot Size/Acreage 1 Owner's Name Address t K24 L 4 IWOP Phone *` Contractor Address $2,5 5• �- h r License No: Sl2zCg Phones TYPE OF WELL/PUMP: NEW WELL ❑ WELDREPLACEMENT n DESTRUCTION Out of Service Well ❑ DISTANCE TO NEAREST PUMP INSTALLATION ❑. SYSTEM REPAIR. _.OT HER ❑ Monitoring Well SEPTIC TANK SEWER LINES DISPOSAL FLO �Y/�� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL!; PITS/SUMPS / INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom Manteca Dia. of Well Exc. ion ! Dia. of Well Casing [I Domestic/Private [Gravel Pack ❑ Tracy Type of Casing. le �� Specifications i'I Public C1 Other 1.1 n Delta Depth of Grout Seal Type of Grou `c I I irrigation Approx.,Depth I 1 Eastern Surface Seal installed by E� _1 11/H4� Repair Work Done L7 Type of Pumpr H.P. State Work Done ' Well Destruction ❑ Well Diameter Sealing.Material & Depth Depth ) Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other s Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:f Water table depth SEPTIC TANK. ❑ Type/Mfg J Capacity No. Compartments PKG. TREATMENT PLT.❑ ; Method of Disposal Distance to nearest: Well Foundation `Property Line �. LEACHING LINE 13No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEF.1oGE PlT5 11 Dept - _ Size= Number_ SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 tihall employ persons subject to workman's eompensa• tion Is of Cl ' rnia." The applic nt mu t call for alt r irad in ons. Complete drawing on reverse side. Signed Title: ✓ Date: L FOR DEPARTMENT USE ONLY9Z T Application Accepted by ' Date Area Pit or Grout Inspection by / Date /'� Final Inspection by Date �! Z Additional Comments: ! I Applicant - Return ails'copies to: San Joaquin County Public Health Services zQs� I t Environmental Health Permit/Services 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 ��I��FE{EM AMOUNT REMITTED ASH RECEIVED BY J DATE PERMIT-NO. ! EH 14-26 aREV. r As) 00f L 6`1 /^EW)3.24 uD l 'FF'