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b Ra w. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445. N SAN JOAQUIN, PHONE (209)468— f � P O BOX 2009, STOC%TON, CA 9520 PERMIT EXPIRES 1 YEAR FROM DATE IS3420 a (Complete in Triplicate) MAR 2 4 1992 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 Rules and Renu one of San Joaquin Cou(n]t/y� Public Health Services. �NVyF�N`� {��p,��ItAIN „I T l /t✓+� City Lot PAW rSe�age' � r Job Address � � --- n p 4-z LJ Owner's Name5tv►'r P Address Phone Uml C10 7�4-a a3 Contractor Address l i rkt f 5_s�L`License No7__ T Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION JPCOut of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well U 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 Pack ❑ Tracy Type of Casing_ Specifications I'1 Public El Other F1 Delta Depth of Grout Seal Type of Grout I 1 Irrigation w,.Approx. Depth I ) Eastern Surface Seal Installed by Repair Work Done U Type of PumpN H.P. Smite Work Done Well Destruction Well Diameter o-� Sealing Material & Depth - Depth rr Filler Material~&,_Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I T INo septic system permitted if public sewer is available within 200 feet.) �- Installation will serve: Residence— Commercial_ Other C/) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No, Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line +° A u LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line MAR 4 1 99 SEEPAGE PITS 11 Depth Size � �Q'zJflu CO_ Number UNTY SUMPS LI Distance to nearest: Well Foundation Property Line �RVC BdAL N SEALERVICES LI DISPOSAL PONDS ❑ H DIVISI 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 y 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 workmen'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 shall employ persons subject to workman's compensa- tion laws of California." The applicant must tail for all reguired inspections. Complete drawing /o1n reverse side. Signed Title:( V Date: �- OR DEPARTMENT USE ONLY f Application Accepted byDate Z--�� Area Pit or Grout Impaction by Date Final rinssppec`tioonn by Data Additional Comments: /� fel/ f ' `� �^'Y p Jam` 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY PATE ?ERMIT'NO. . EN 17.24(REV.t in 5) V O r © 0 �Y © r 1-3345-Ek11-2a ✓