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` APPLICATION - x SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIESE. ENVIRONMENTAL HEALTH DIVISION R t n V" ., 445 N SAN JOAQUIN, PHONE (209)468-3420 2 P O BOX 2009, STOCKTON, CA 9520 r FEB'ENVIRONMENTAL HEALTH 1993 PERMIT EStPIRES I YEAR FROM DATE 1SSUEt�ERM1T/H CM53 (Complete in Triplicate) ` F 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 c0=Pliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules acrd Regulations of San t Joaquin County Public Health Services. // {I,Q i Job Address cl t� +<Je/!d /; City �' 4� Lot Size/Acreage' Owner's Name �,ell�', �C! Address _43&71?L R'S r'D& /A462-,637�L2 � V(��rs�c�t.p Gro �}��a I �J Contractor__ � -��o (G-1CPS )Address �74� �(1t;.s �/J0,04 /dl t J�J�(o(akLLJ__5_21 se No. Pho -U-/b�p TYPE OF WELL/PUMP: NEW WELL ❑� WELL REP AGEMENT ( DESTRUCTION ❑ Out of Service well Cl PUMP INSTALLATION ❑ SYSTEM RE�AlA ❑ OTHER sdf` tcring we�3 ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES S� DISPOSAL FLO. PROP. LINE��, �F FOUNDATION �` AGRICULTURE WELL OTHER WELL PITS/SUMPS " INTENDED USE TYPE OF WELL PROBLEM AREA - CONSTRUCTION SPECIFICATIONS - x C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C1.Dolmestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I 1 Public Other Cl Delia Depth of Grout Seal Type of Grout i I Initiation A Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destrugtion ❑ Well Diameter a Sealing Material i Depth �JdlL�f�lAl� Depth Filler Material i Depth TYPE OF SEPTIC WORK; EW INSTALLATION I I- REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is i 200 feet.) „ available within Installation will serve: Resident Commercial Other Number of living units: Num f bedrooms 4 ' Character of sol!to a depth of 3 feet:' Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑3 ""` Method of Disposal Distance to nearest: Well Foundation Property Ulnen t LEACHING LINE ❑ No. fi Length o Total length/size t ^ FILTER BED 0 Distance to nearest. Foundation .Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS LI Distance to nearest: Foundation Property Line DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquhi county ordinances, state fav4is;`-'end: s rules and regulations of the San Joaquin Co..:nty — _ 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'sh"alliibt employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalhemPloy persons subject to workman's compensa- tion laws rnia." The appli an m to fox all requ ins ctions. Complete drawing on reverse side. ' T t Signed X Titla: �og_ CeXg&n�1P4.tcKWG Date: Z•- r R DEPARTMENT USE ONLY Application Accepted by Date ArAa Pit or Grout Inspection by ate Final tnapection by Additional Comments: •'� I 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 &T1Xe FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH AECEIVED ay GATE PEAMIT NO. • EM 37.34 INEV, iiM� EH 11.28 fwd— 3x8 g a �9 rl��.i � 3_ C�s� h j