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APPLICATION- Aft SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION � t 445 N ,SAN. JOAQUIN, PHONE (209)468-3420 APR 0 9 1993 top P O.BO% 2009, STOCgTON, CA 95201 ENVIRONM�N?�� I��A�.�'I� RERMIT/S LUKE �``"' PERMIT EXPIRES 1 YEAR FROM DATEISSUED, (Complete in Triplicate) ` Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This j application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San 'f Joaquin County Public Health Services. Job Address olhualt!li Cite Lot Size/AcreageAC� Owner's Name r �C �r Address -� 4 `�C ��J Phone Contractor Address In � 1�`�` _License No.222yc _Phone 3(, TYPE OF-WELL/P NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 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 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing j C) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 4 I'l Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump 4cpH..P. 61.4 State,Work Done Well Destruction tM. I �Well Diameter Sealing Material h Depth Depth Filler Material & Depth . TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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 Character 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 C) No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGVPI-TS ---- I-I ... _ N Depth -_, _ --Srze= :� umber.. i SUMPS LI Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ s I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I 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 laws of California." The applicant must callNr all required inspections. Complete drawing on reverse side. ` Signed - Title: ' all 6,4 e Date: l i - f Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date i Additional Comments: 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 CK EIVED BY DATE PERMIT'NO. ! EH 13-24 IREV,I/ EH-11.26 V I