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SAN *QUIN COUNTY PUBLIC HEALTHVICES ENVIRONMENTAL HEALTH DIVISI 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servicess.t-� Job Address 4707 PdClf10 Ave ARK 10- 140- CityStOCICbm Lot Size/AcreagelrOM sq. ft. Owner's Name lAroC l G20)QL"ictl(Yl AddressP.Q. Eox 5155 San A 9(.SR _ f C n Phone Contractor W�tex AddressU0. aZ 1664111 22920 nt ,License Nose Phon�916 111q TYPE OF WELL/PUMP: NEW WELL N WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)C Monitoring Well JW !t TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. !t NEL) FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1L in Dia. of Well Casing(? in C.1 Domestic/Private )1 Gravel Pack ❑ Tracy Type of Casing SC11. 1 Specifications I') Public Ll Other Cl Delta Depth of Grout Seal �D ft_ Type of Grout Nkat Cpmmt I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by__TIr-illm- Repair Work Done ❑ Type of Pump _ H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Bmtcnite. 47_Vl�tl- t��r1.face Depth Filler Material & Depth #3 M,1TtPr 4 saryl TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 No septic system permitted if public sewer is available within 200 feet.) 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size 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: "1 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: "1 certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." The applicant at cal or all re it d ins tions. Complete drawing on reverse side. Signed Title: Owner Date: .10)z 99, 1992 OR DEPARTMENT USE ONLY `ice /0, �/Z � ST-1 �1I Application Accepted by� Date 'y�+/j`��- L [.i Area `�n� Pit or Grout Inspection byeA.'','I 1 t�.DDa�te $ 113e�2 Final Inspection by-/f/gw Date Additional Comments: 1nYV_T(1 &I (IYWA d sly. ADKTipqiA Applicant - Return all copies to: San Joaquin County Public Health Services _J Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE 11111 AMOUNT REMITTED CK flECEIVEO BY DATE PERMIT NO. �ICASH . EH; 3.24(REV.1/8 sl / OD 25�-� 3 n• QEH 4.25 4 /Q�r J ' WP I is