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Ti I AUG 16 19g4 -- / 1111 i ,... , , Owner's Name Ma...rjor i C-. C-rmradli Address _- . b A . •hone r ", Contractor NI I i-C-hell Dr.1 i i llier AdressPb 2:02( 2251 athCAZAttLicense No. Phone 9/i#15; TYPE OF WELL/PUMP: NEW WELL ,X. ' WELL REPLACEMENT El DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1/ Cl Industrial 0 Open Bottom Cl Manteca Dia. of Well Excavation V( Dia. of Well Casing f„, El Domestic/Private Gravel Pack Cl Tracy Type of Casing P VC-- Specifications I'l Public [1 Oyler 7 Delta Depth of Grout Seal i 8 4 Type of Grout 35' la Approx. Depth I Eastern Surface Seal Installed by , I Irrigation . Repair Work Done (3 Type of Pump H P State Worts Dqne .e^ai -F5 :3Z , UAL I g r Well Destruction 0 Well Diameter Sealing Material i Depth C..e/Yd— t Depth Filler Material & Depth $j //s e ___ ..Sa-114.... -(itted-pote.K.JeliaCki TYPE OF SEPTIC WORK: NEW INSTALLATION ' REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 it Area FEE INFO 401 AMOUNT DUE AMOUNT REMITTED CK i CASH RECEIVED BY \', DATE PERMIT NCI . . _ _ gmq e9r /30 -5eo- gal . Em 13-24 (REV 5) EH i4.26 APPLICATION AID #. FAC # \I SAN JOAQjJIN COUNTY PUBLIC HEALTH SERVICES EN RONMENTAL HEALTH DIVISION 445 N AN JOAQUIN, PHONE (209) 469-3420 P 0 OX 388, STOCKTON, CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTH PERMIT/SERVICES Application is hereby made to San Joaquin County for a cx=it to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Development Title Section 9-1110.3 and Se...7ton 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. N Cit y 5-1-oc44nt Lot Size/Acreage 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 subiect to workmen'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 laws of California." The applicant must call for all required inspections Complete drawing on rev rse side. Title: FOR DEPARTMENT USE ONLY Signed Date: P4D;te PHS 133 (2194) Application Accepted by Pit or Grout Inspection by Additional Comments• Date Final Inspection by Applicant - Return all copies to: Si Joaquin County Public Health Services Ezvironmental Health Permit/Services 445 N. San Joaquin, P.O. Box 388, Stockton, CA 95201 88 ,_CR tcr