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APPLICATION FOR PERMIT : . ` .: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION � P O BOX 2009, STOCKTON, CA 95201 MAR 2 5 1991 (209) 468-3447 CNVIRO!!MENi'A! HEALTH ER�_BXP-_LRES ,1.,,YEAR fROM. RADE ISSUED PERM11/S�:RV;Cr7 ` (Complete in Triplicate) Es Application is 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. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services, Job Address .10133- W- C-OZEIP RO., City`TRACV Lot Size/Acreage Owner's Name �"'/SA1�/C[S _FIA24- LCISCr Address %093 ►g/__ ('1I1VFi2 rd� Phone 1-2 Contractor C/ALW IMP, DkU1W*.ress L icense No. Phone - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ USTRUCTION put of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 Y � n Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications Z) Public 1.1 Other © Delta Depth of Grout Seal Type of Grout f CI Irrigation _.Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump / H.P. State Work Done_ Well Destruction �— wolf Diameter _!e IAIQ[ Sealing Material i Depth Depth ZC:j Filler Material i Depth TYPE OF SEPTIC WORK: NEW"INSTALLATION 0 REPAIR/ADDITION CI DESTRUCTION G INo septic system permitted if public sewer is _ available within 200 feat.) Installation will serve:" Residence_ Commercial r,.. Other 3 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: Well4-"j" Foundation Property Line II LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line V SEEPAGE PITS 11 Depth P Sire Number SUMPS LI Distance to nearest: well Foundation Property Line DISPOSAL PONDS El --- -- � - I hereby certity that 1-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 Joapuin County i 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 applic us ca for all r q iced inspections. Complete drawing on r arse :id , Signed - Title: Date: f // R DEPARTMENT US ONLY Application Accepted by pats 3- � Area +� Pit or Grout inspection by a final Inspection by DateL Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PZRMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 FEE TINFO AMOUNT DUE AMOUNT HEMfTTED CK V CASH RECEIVED BY "DATE AERMIT'N0, l . EH 13.24 IREV.iiw51 �jlV 601'-r �(J EH:x•26 YY u/„�. A-