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SAN jL4UIN COUNTY PUBLIC HEALTH S ICES IINV I RONMENTAL HEALTH DIVISION PAYMENT 445 N SAN JOAQUIN, PHONE (209)468-3420 RECEIVED P 0sox 2009, sTccxTQN, CA 95201 AUG US. 1992 I PERMIT EXPIRES 1 YEAR FROM J]ATE IS9UED_- SAN QUA tJ►Iq . (Complete in Triplicate) PUBLIC HE L,t.t ,,t a t"._o Application is hereby made to 3ets.Joaquin County for a-permit to construct and/or installIrl.dd c :l+edl:'rr t j' application is made in ccap'liance with Sass Joaquin county ordinance No. 549 and 1862 and the .Rules and Regulations of San Joaquin county Public Heath Services, , City J I"M Wt Size/Acreage Job Address Phone Owner's Name +J fI"t Address ,i f 1 kLi r. 1 Address « 2 - 0 ,- Contractor tt }c License t +i, -`1 f'hcrne ' TYPE (}F WEILtPUMP: NEW WELL 0 WELL REPLACEMENT (-ID£STRUCTkON 71 Out of Service Well Gl SYSTEM REPAIR 0 OTHER A Monitoring Well x PUMP INSTALLATION C-1 r l��":«�e'��fiwt�f '',.. DISTANCE TO NEAREST: SEPTIC TANK >f'DO SEWER EINES r r DISPOSAL P�.D, too�G� " 1 t PROP, LINE e-ItAcot ort FOUNDATION AGRICULTURE WELL ?_LDI) -OTHER WELL_�!� PITS/sumps uxI(: tC�iCrr"1G INTENDED USE TYPE OF WELLPROBLEM AREA CONSTRUCTION SPECIFICATIONS � t _.- t 1f"I1 C' �tJ' n r t ' 0 industrial © Open Bottom CI Manteca Dia.-of WeIf Excavation Dia. of Well Casing Ct DomestictPrivate X Gravel Pack 0 Tracy Type of Casing_ Specifications I"t Public FI Other VoeltaStr?C K ldre Depth of Grout Seal :4 � C!hc te-SC�t°dh Type of Grout • ►�`' { I i Irf"gation Approx. Depth I I Eastern .. . .Surface Soul installed by { Repair Work Done 0 Type of PumpH.P. State Work Done Wait Destruction 0 Well Diameter Sealing Material & Depth Dept - {� h Filler Material & Depth .-- TtdC1t 4 l TYPE 09 SEPTIC WORK: NEW INSTALLATION i I REPAIRIAOOITION I I DESTRUCTION i i (No septic system permitted it public sewer is { 1 available within 200 lest.I m I' installation will serve: Residence Commercial Other >; Number of living units: Number of bedrooms -- i Character of soil to a depth of 3 feet Water table depthn SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKC: TREATMENT PET,Cl Method of Disposal Distance to nearest; Well Foundation Pro party line LEACHING LINE El No. & length of lines Total lengthtsiza FILTER BED 0 Distance to neatest. Well Foundation - Property Line ".' t SEEPAGE PITS l I Depth Size - _ Number SUMPS Ll Distance to nearest: Well Foundation Property Lina r DISPOSAL PONDS C] I I hereby cenity that I;have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and r rules and regulations of the San Joaquin County m Home owner or licensed agent's signature certifies the following "i certify that in the performance of the bark 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 sols contracting signature certifies the following:''_I certify that in the performance of the work for which this parmit is issued, I shall employ persona subject to workman's compensa- tion low*of California." The applicant must call for all requir inspoctions. Complete drawing on reverse side. Signed X Title: S Date " 11r 445Z(06 Yo FO DEPARTMENT USE ONLY i v Data ".. Area Application Accepted{by Pit or Grout Inspection by ` Data _211" r 2_Final Inspection by ` "L i t Ti Date t+r i Additional Comments: i Applicant - Return all copies to: - San-Joaquin County Public Health Services Environmental Health Permit/Services 4=45 N San Joaquin, P 01 Box 2009, Stkn, CA«852011 _FEEs INFO AMOUNT DUE' AMOUNT ftEMitTEfl CASH t�E£El51ED By (y HATE PERMIT`_NO. is EH t}}2i tRE1t„errs s! EM ti•2b tJ f'�