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SAN *QUIN COUNTY PUBLIC HEALTH *VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Rules and Regulations of San Joaquin county Public Health Services. Job Address 4237 Px'fir Aia= ( ff •f AIN 1 I Sk1101 P 93 City Strrktm Lot Size/Acreage a_0M_g fY Owner's Name LbO:'al (4n=tim Address 12.17_ Per 5155 S REjum CA CL Phone( _ Contractor WeStjeX Addressp O Rim 166(4 [•T S i-n, CA License No. 557148 Phon TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation R in Dia. of Well Casing C:l Domestic/Private X1 Gravel Pack ❑ Tracy Type of Casing S:h 40 Ar. Specifications ('1 Public Cl Other Il Delta Depth of Grout Seal 50 ft. Type of GroutIll�at 1 I Irrigation _Approx. Depth�e I I Eastern Surface Seal Installed by T)Hllpr Repair Work Done ❑ Type of Pump -N/A H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material a Depth Rentmit-e A7_g1 /ys.,,r- Depth Filler Material a Depth #_3 ante3gZ wall a 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.) Installation will some: 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. compartment; 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: Welt Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 lawn of California." The applicant In III i call r all requi ed i s cti s. Complete drawing on reverse side. Signed Title: Owner Date: Jul 29 1992 FOR DEPARTMENT USE ONLY Q z1.DV Application Accepted by C' p Dale v• Area Ln� Pit or Grout Inspection by J_/I_/ILYY Dare 7] • • 2- Final Inspection byfkwma '6.23• Z - -- " - Date Additional Comments: 1v1W 11D1IQ t 11 5149LAbLLK WN 1Ip.2,5D 1)Lvi g Applicant - Return al I copies to: San Joaquin County Public Health Servic s Environmental Health Permit/Services �V 1 per U., 445 N San Joaquin, P O Box 2009, 3tkn, CA 95201 e FEE AMOUNT DUE AMOUNT REMITTEDI IP INFO CASH RECEIVED By DATE PERMIT?NO. . fH 17$4IREV.Irxsl $ Z!• 25y3 n�rn �• � 52 92-2? JH 13 7a N\W9