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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PAYMENT 445 N SAN JOAQUIN, PHONE (209)46830 P 0 BOX 2009, STOCKTON, CA 952Q MANArEl .'�jv j) PERMIT EXPIRES 1. YEAR FROM DATE ISSUED N 14 1993 (Complete in Triplicate) SAN JOAQUIN COUNTY PUBLIC HEALTH �NxVR9W hMLTRYACES Application is hereby made to San Joaquin County for a permit to construct and/or install the sror ftWSIQN 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. Job Address 7-500 v �L City SLJkL*N Lot Size/Acreage Owner's Name �`r� o� 5 �'��L,.^ Address LtLT W � i-, k 6nMk-, S�. Phone ii� 7+�[ �ST� Contractor s CL1r`�+`�^ Address r1 '. License No.��t,r�,�_� Phone TYPE OF WELL/PUMP: NEW WELL C1 WELL REPLACEMENT n DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ Monitoring Well I{ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 14J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 17 Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications I'1 Public C7 Other n Delta Depth of Grout Seal Type of Grout I i Irrigation _.Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. Stat Work Done r Seals Material i Depth (2�Md�ty - ta Well Destruction X Wel! Diameter Z � eP Depth .r Filler Material A Depth ineA� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.) N 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 ❑ Type/Mfg Capacity No. Compartments O PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Properltli J elf RAT LEACHING LINE ❑ No. & Length of tines Total length! I FILTER BED ❑ Distance to nearest. Well Foundation Prop ones 1 1993 TY SEEPAGE PITS 1 I Depth Size NumbRV10E SUMPS L: Distance to nearest: Well Foundation 1151� �AL� 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 subcontracting 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 ust call all r ired inspections. Complete drawing on reverse side. y/►,, �,/�,� 7 Signed r Title: _11__ 61 1 f'��7 t- ! Q- Date: 3 F R DEPARTMENT USE ONLY Q Sr Application Accepted by Date �n,�,�J�n _ Area [ 'CY0 Pit or Grout Inspection by Date�_ Final Inspection by__ 2� / ►'`-` Date 6.21' j Additional Comments: _ C U5 FI — wo �,k\ in amru `t- Y'@5tsf c L( WI 45�It Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE CK I INFO AMOUNT OUE AMOUNT REMITTED �C}A�SH[ RECEIVED BY f rDATE f]PEERMI-I'NpO. . EH 13-24 IREV,I/x Sl � �� ;�Q L.tO/ t!/'1 tP ' �3 `I 0� EH 114.20