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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 i r- t P O BOX 2009, STOCKTON, CA 95201 E " PERMIT EXPIRES I YEAR FROM DATE ISSUED MAY 12 1992 (Complete in Triplicate) 1�-NVERONMENTAL HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the Work �e�e YL11 uyluss 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 c),12-7 7 L ) City Lot Size/Acreage ...r7 Owner's Name Address Phone �v ' L P Conlraclor Address Incense No. I Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT TDESTRUCTION ❑ Out of Service well PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER C1 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP-LINE! i FOUNDATION AGRICULTURE WELL + OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA;'+CONSTRUCTION-SP-ECIFICATIONS r ❑ Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications i'I Public 1 f.1 other C 1 Delta Depth at Grout Seal Type of Grout i I I lrri0ation ��Approx. Depth l I Eastern Surf ce Seal Installed by s f ` Repair Work Done 0 Type-of Pump H.P. , f 1 State Work Done `y 1 Sealing Material &Depth Well Destruction ❑` Well Diameter �p�.-_ Depth r !Filler Material & Depth `\' i TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is �� i available within 200 feet.) f Installation will serve: Residence— Commercial�' Other + k Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: ' Water table depth ! SEPTIC TANK. ❑ T ' 1 ype/Mig Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of.Disposal `, I Distance to nearest: Well Foundation Property Line LEACHING LINE L-I No. & Length of lines i Total length/size FILTER BED ❑ Distance to nearest: Well Foundation I Property Line SEEPAGE PITS 'I I -cia IR Sire Number _ SUMPS a t LI, Distance to nearest: Well ' Foundation Property Line { DISPOSAL�P DS ❑ -. - I hereby certify that I have prepared this application and that the work will be done in accovdance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County f - Home owner or licensed agent's signature certifies the fallowing: "I Certify that in the performance of the work for which this permit is issued, I shall not employ any person i ch manner as to become subject to workman's compensation laws of California." Coniractor's hiring or sub-contracting signature certifies the followin . "f certify theuin the performance of the'work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws alit la*' , 3 The app st all for all requzrinspectiZ. omplete drawing onside. 3 Signed Title: 1r; Date: FOR DEPARTME USE ONLY ' 7' Application Accepted by + Date Area 2r ! 1 cr Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: r I Applicant --Return-a-1-1-copies-to.- San Joaquin-County Pub-l-i-e-Hea3-th. Services I , Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED CASH CK A RECEIVED BY DATE ' PERMi7'NO. • E„1324IREV.+inSi �/ ; Dv EH 14-2a