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C� i30�r SAN ANWAQUIN COUNTY PUBLIC HEALTHVICES VIRONMENTAL HEALTH DIVISIs� yob" A � 445 N SAN JOAQUIN , PHONE (209)468-3420 k` P O BOX 2009, STOCKTON, CA 95201 -JUL 0 1 1993 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CCnf�II ��nf�r��n�� (Complete in Triplicate) Appl1c6t'lJdsWAAEhJA6"EA �an Joaquin County for a permit to construct and/or install the work herein described. This Ill ftMWSERVI"Iiance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address l 1 0 FDCT mnDntt:n� — City T.flpj Lot Size/Acreage Owners Name T• It_STRF-CAT, Address 110 EAST TURNER RD LCIDI Phone 33.nr .iense N 5' -?ZJ Phonp2p 16 /5' r Contractor -�n5 / i License No. TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O Out of Service hell O SYSTEM REPAIR 0 OTHER ix "�oniring Well LT PUMP INSTALLATION O k [jt)C�•r ti �• DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES bl DISPOSAL FLD. N PROP LI E NA FOUNDATION NA AGRICULTURE WELL _11A - OTHER WELL NA PITS/SUMPS -NA SB- 1 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom O Manteca Dia or Well Excavation Dia. 01 Well Casing 'Jglbs i 1 Domestic/PrivateType of Casin Cl Gravel Pack O Tracy 9- Specifications Type of Grout I'l. Public Cl Other FT Delta Depth of Groin Seal Ge I I Irrigation _ Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done Ll Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material it Depth Depth Piller Materiel i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I ,Neil epeiw snit system permitted if public sewer is Installation will serve: Residence _ Commercial_ Other Number of living units: _ Number of bedrooms Water table depth Character of wil to a depth of 3 fast: SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest. Well Foundation Property Line LEACHING LINE CT No. 6 Length of lines Total length/size FILTER BED O Distance to newest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number - SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS O 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 subcontracting signature certifies the following: '•I certify that in the performance of Ins work for which this permit is issued, 1 shall employ persons subject to workman's compensa tion laws of California." The applicant mushcall ler all r quj7r inspaoinsAomplete drawing on rever� side. �} Signed X- �, — Title: — Date: / -�" - •-/ FOR DEPART",- 1,y SE L7,Q 17,I Application Accepted by �"� .i Date . . 1-1�, _ Area Pit or Grout Inspection bye .inal Inspection by Date Additional Comments: n1v ""^"' Applicant - Return all copies to: Ben Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Boa 2009, Stirs, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED eV DATE M INFO . Eril7r(REV r,as�j V iO V V0. vc) two � 3 fN Ir m