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r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT ENVIRONMENTAL HEALTH DIVISION � � � 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 .Ri E P 2 1 1992 PERMIT EXPIRES 1 YEAR R FROM_DATE ISSUED5,4N,JOAC�Wi Cr1JRip( 1{: s�,,.,� lrALTf�r �!��'1/jCES z (Complete in Triplicate) " NTA HULI�). DWISsDN Application In 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. 5h9 and 1862 and the Rules aad Regu San Joaquin County PPuubb�lic Health Services. Job Address / "a """r � � __--_ City-� � Lot Size%Acreage t9,3 Q U �K loo �OQ � 5 L70 �"9 me ' on( Owner's NS � d �8 Contractor r4oaaks -rarr Address 360 PkL��nsMo. d57jq*AoneC6_/0)4f16Z' O TYPE OF WELL/PUMP: NEW WELL 0, ilyyl/-¢ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well 0 PUMP INSTALLATION ❑ f SYST MREPAIR ❑ OTHER Monitoring Well SYSTEM soi�aORWO DISTANCE TO NEAREST: SEPTIC TANK �V1� _ SEWER LINES / /V /:�1PNSPOSAL FLD, PROP LINE FOUNDATION AGRICULTURE WELL �- OTHER WELLa I � - ETS/ PS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industria MGy»'orYr1�>❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing Cl Domestic/Private Gravel Pack ❑ Tracy Type of Casing. Pyc_ Specifications-Y� wprk play I'1 Public I 1 Other ❑ Datta Depth of Grout Seal ep' f Type o1 Grout PD rta�GP/na I I Irrioation 8 .Approx. Depth I I Eastern Surf ce Soul Installed by Repair Work Done U Type of Pump H.PState Work Done Well Destruction ❑ Well Diameter Sealing terial i Depth r r Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION E I DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units; Number of bedrooms Chef acter 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 C1 No. b Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS l.1 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 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 must call for all required inspections. Complete drawing on reverse side.Cs�/� ar� Signed X 1 Title: � u (r ep<G Mall" eAiAC, FOR DEPARTMENT USE ONLY 9 � 7,?,00 Application Accepted by Date �� ' ! Area /LI Pit or Grout Inspection by Date IJ' --final inspection by Date.hZZV Additional Comments: �S'LL �Q(.1(3-�j Z - 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 INFO AMOUNT DUE AMOUNT REMITTED �jCASH RECEIVED BY J DATE PERMIT'NO, . EH 13.24 IREV.i 1".5) �q �� ✓�� ! r f q x5.92 12-3Z � EH 14-M