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SAN *QUIN COUNTY PUBLIC HEALTHVICES ENVIRONMENTAL HEALTH DIVISIO 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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 4707 Pa 'fir Aro ( ff i fe All\ 3 Pk 109i P 93) City St r-ktm Lot Size/Acreage' An Sq ft-- Owner's Name Uf=l QM LT dM AddressP O Pnx 5155t ca., am:l � Phone - Contractor TAJbStEX AddressP EOX 166/+W CA['t'r�1a t0 CA License No. 557198Phone 9J 6)373-111 R TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ❑ Domestic/Private V Gravel Pack ❑ Tracy Type of Casing Sch.••.,_40 PAX' Specifications I'I Public I1 Other FI Delta Depth of Grout Seal 90 ft_ Type of GrOr&J2at Ckn1ant I I Irrigation _Approx. Depth I I Eastern Surface Soul Installed by Driller Repair Work Done L7 Type of Pump — H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth PmUCQJtQ7 gj;CL1t togTf� Depth Filler Material & Depth #3 M�n�t�t'a3: v TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.I 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 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 certifies the following: "I cenify 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 applica ust cal r all requi in act' ns. Complete drawing on reverse side. Signed X Title: Owner Date: July 9 1992 FOR DEPARTMENT USE ONLY Application Accepted byj Data i Pit or Grout Inspection by Date ta/ 12 Z- Final Inspection by Data,111-14-U- lIZ 61&Additional CommentslK 1.2 - v'YN 155�� 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 I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BV DATE PERMIT NO. INFO ��//'' �/[�9 //M/ �/ �^(.�/ ESA • . EH 17*3x(REV.iixS� 7�q OO U I. a/V �✓ 13 RA. rA �• �•�Z / Zz1 EN I�M VV MW �2