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RI SAN *QUIN COUNTY PUBLIC HEALTH *VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 ;1 P O BOX 2009, STOCKTON, CA 95201 _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1s 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 Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Ct-rlrtm Lot Size/Acreage � tit Job Address- /707 Pa "fir Ayc,�pff3i tPr AIN t Rk 10gy-�.1hT City - S Cm el CA 9!aSR� P1104 - Owner's Name lhrral (hm3t�atim Address P-0, Box 51 C ,..,..--.-tr vs Contractor WesteX Addres P 0 Box 1(64W S'�nu2ntQ fA License No.592198 PhonF TYPE OF WELL/PUMP: NEW WELL IE WELL REPLACEMENT Cl DESTRUCTION ❑ Out of service Well Monitoring Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CD 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 C7 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing Type C:l Domestic/Private Gravel Pack T❑ Tracy YP of Casin 9S"h /0 Pim' Specifications Il Public f:l Other n Delta Depth of Grout Seal 50 fi-- Type of GroutNaat rarpnt I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump CTIA.- H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth 1;-;t-mitp,I /7�&-tn %11-Pace Depth Filler Material & Depth# ' s33d TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (Nailableo septic withm permitted if public sewer is 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 Cl 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, 1 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 laws of California." The applican ust ca r all requir d ns Ions. Complete drawing on reverse side. Signed Title: Owner Date: July 29. 11992 FOR DEPARTMENT USE ONLY 1K Cf U O� Application Accepted by Date " • ` Area - Pit or Grout Inspectionby&/�`�.�I� Dalai-131?:— Final Inspection by ( Date Additional Comments: deinaaik �PN � ' �WV+ W/ C05 DP_✓ou5g31001 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 AMOUNT DUE AMOUNT REMIT-TEDASH CRECEIVED BY DATE PERMIT'N0. INFO . EH 1331 10 EV.six a l EH 1410 MWD-rMwtl t