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SAN JOAQU I N COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RECEIVED 445 N_SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 SEP 1 4 1092 PERMIT ESPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH p�RMIT/��RVEC�S (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install a ribed. This � a application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and iTJQions of San Joaquin County Public Health Services. C� q � Job Address � SGfit �+�ieTi4G ` I)00 W ity_ Lot Size/Acreage 1%�r6H /fcTch's- 1ll4TE2 41W 1"OIU�le D, Sox /64 G/ �ltiD `DWX1r,t' 4F '�' � '�G/sc� }ICC�45'l�y� G9• 95347 Phone 2A9 9� 243/ Owner's Name .„_Tf' Ad rasa _ _ Contractor �' Address X/ A' License No. _ y�- Phone y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION�PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Crl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications I') Public Cl Other fl Delta Depth of Grout Seal Type of Grout I i Irrigation — Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 8 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION A-DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) C� Installation will serve: Residence✓ Commercial_ Other DfF/C., O Number of living units: / Number of bedrooms 3 Character of soil to a depth of 3 feet: CLfJr 141/71' A V'.ty S'MALG ffOe4l'flE 01c S�Water table depth SEPTIC TANK. LP"Type/Mfg /.704ilF iYYGEyE s�/C Ti /,C Capacity -/504 9LS- No. Compartments Z PKG. TREATMENT PLT. ❑ Sr Al, C. y��/' H�� ev" Method of Disposal LC�Y�' F/EGD Distance to nearest: Well NG Avg Foundation 1470 /-r, Property Line m LEACHING LINE C1 No. A Length of lines - i6 0.1-7. Total length/size 3Z0 F� FILTER BED ❑ Distance to nearest: Well N47 Foundation 296 Fr- Propeny Line (/t SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 sub-contracting signature canifies 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 st call ford inspections. Complete drawing on reverse side. u/� Signed I OM�r� fr�4 Li9ui Title: _ �✓V/G ��/�'/tiG�it ,_ Date: ��07' io, /992 =Z!,ARTMENT USE ONLY2—Application Accepted byDate Z� Area f 6 Pit or Grout Inspection by Date Final Inspection by Date D Additional Comments: ____ t,&P!Kt 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 CK RECEIVED BY DATE PERMIT'NO. qu 15310- + EH i,m rn¢v.s x sr f�7�•GrZJ r1 T' ZtS /Z 6f �i'� _ 3