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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUINr,. PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Complete in Triplicate) f Application is hereby msde•to San Joaquin County for a.permit to construct and/or ins_taLt 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 San f Joaquin County Public Health Services. E Job Address 1 3885 Eight Mile R _ City T.inrlen Lot Size/Acreage f Uaccarezza Br L _ Address Phone �_$2 Owner's Name . — Contrac&i rvi.ance Drilles, , nq,, POBOx 6L Linden License No. 377923 Phone 887-3554 ,.-- TYPE 87-355 `"TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION)UcOut of Service Well ❑ € PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L3 ! 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 — n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing FI Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications K 1'1 Public 17 Other n Delta Depth of Grout Seal Type of Grout I I Irfigation _ Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H,P, State Work Done Well Destruction Well Diameter Sealing Material & Depth ceirtent II - i�pthsand et e Filler Material & Depth !I ! TYPE OF SEPTIC WORK: NEW INSTALLATIOWI 1 REPAIRIADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is ,available within 200 feet.) instailation will serve: Residence Commercial,____ Other Number of living units: Number of bedrooms �. Character of soil to s depth of 3 feet: '`" y Water table depth SEPTIC TANK ❑ Type/Mfg Capacity—, , No. Compartments PKG. TREATMENT PLT. ❑ ;, Method of Disposal {` Distance to nearest: Well Foundation Property Line ,.�,^�..,..-«.... - '.: Sats-.ew=--�r''+.�i�oe�T7.e.s.+ll. '-wrr� •�, I� LEACHING LINE ❑s No. a,Length of lines Total length/size ` f k FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size ° Number i! SUMPS L1 _Distance to nearest: Well Foundation Property Line F 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, an 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 ertiploy persons subject to workman's compensa- tion laws of California." Theflica�nnII )SI tail r al equ-r d inspections. Complete drawing on reverse side.SignTitle: 3 Oats: 4/21 /92 ti is FOR DEPARTMENT USE ONLY Id C :I Application Accepted by Date Area — Pit or Grout Inspection by �Date /y,Final Inspection by��/ cr7 Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 i' IN O AMOUNT DUET AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO, II EM 13.24 iREV.rin5i EH 14.26 M