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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES DU 1-OF- rL+�l ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 I P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISS UID �{ (Complete in Triplicate) � Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the RuINAERd Oehu is of San Joaquin County Public Health Services. g(q ``�� q4l...&& S-�c,��nn ✓P Cit Lot 51�IVV 1 Job Address -- Y Owner's Name� Paper 0-6. Address P10-460K 7 ]7r 91"066A `j636 (I Phone(`! Contractor a Address��1 C yicen�e No.��CPfton) '0I703 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION I<Out of Service Well -... PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 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 El Domestic/Private ❑ Gravel Pack7 L3 Tracy Type of Casing_ Specifications I'i Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth 1 I Eastern Surface Seui Installed by r „ Repair Work done U Type of Pump H.P. tate Work Done. �J) Well Destruction Well Diameter ^ppcl sealing Material A Depth i Depth 1 S ie�'{' Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION ! I DESTRUCTION I I INo.septic system permitted if public sewer is available within 200 feet.d�s PAYMENT ALE�owpi!" Ins tallation will serve: Residence____ Commercial— Other i�I�1YM N Number of living units: Number of bedrooms RECEIVED Character of soli to a depth of 3 feet: Water table depthMAR 4 1992 + SEPTIC TANK ❑ Type/Mfg Capacity No. Compart PKG.:TREATMENT PLT. C1Method of Tr SIG Distance to nearest: Well Foundation Property Line ENVIRQNMENTAL HEALTH DWl N LEACHING LINE D No. & Length of lines Total length/size Y FILTER BED [I Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number r SUMPS L1 Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ y 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 k 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 taws of California." Contractor's hiring or sub-contracting signature I certifies the following: I cern that in the performance of the work for which this permit is issued, I shall employ" N Pe p p Y persona subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. l I Signed X ;'�fi� !/14 _ Title: !4 Srd S-� Date: !t�f r FIRR DEPARTMENT USE ONLY Application Accepted bynja� Pats�+.�. 3'?-n�Z - -- Area Pit or Grout Inspection by Dat Final Inspection by Date i Additional Comments: I Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE €; INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT NO, . EH13.i{2a 24{aEY.I/MSS EH �r�� 3—CN—Q9 R'A (/ [j rte.