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APPLICATION FOR PERMIT � ppSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES tom' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 j P O BOX 2009, STOCKTON, CA 95201 �� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ZA��' S � �li� (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This ,applicatian.fia made. '. compliance with San Joaquin County Ordinance No. 549 and 18Q and the Rules and Regulations of San ,:,Joaquin'. oianty Public Health Services. 4PIV#X550-.Z -D0I 1 Job Address "City Lot Size/Acreage Owner's Name r_Al! �M C MI IX A 1 Address �!�� J e ''�_� ��`< �jCi Phone -' -77 Contractor P✓>U -di Address 2S J a& © License No. Z�fQd'�3_Phone TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Gl PUMP INSTALLATION ❑ SYSTEM,REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 620 �- SEWER LINES DISPOSAL FLD.,,�& PROP. LINE FOUNDATION AGRICULTURE WELL - - OTHER WELL PITS/SUMPS " O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation /,2 " Dia. of Well Casing Domestic/Private Gravel Pack Tracy Type of Casing_ Y0Ve_. _ Specifications V] Public n Other n Delta Depth of Grout Seal 1 _ Type_$f Grout &Ahzl'7 I I Ifrigation ._.,_Approx. Depth I I Eastern Surface Saul Installed by s / 1 Repair Work Done LJ Type of Pump H.P. State Work Done— Well Destruction O Well Diameter Sealing Material ori Depth i �I Depth Filler Material A Depth !i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION l I iNo septic system permitted if public sewer is t5l available within 200 feet.) Installation will serve: Residence—•—• Commercial— Other Number of living units: Number of bedrooms Character of sop to a depth of 3 feet Water table depth y SEPTIC TANK ❑ Type/Mfg Capacity No. CorENT PKG. TREATMENT PLT.❑ Method F412a2 Distance to nearest: Well Foundation Property Line RECEI �1 _.,, ..,....-•---------- MAY 0 61993 ' LEACHING LINE ❑ No. 5 Length of lines Total length/size lit ,[[ FILTER BED O Distance to nearest: Well Foundation Propertti. 5RVICES G vAlTW nIVISIQN SEEPAGE PITS I I Depth Size Number ' SUMPS L1 Distance to nearest: Well 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 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 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 shall employ persons subject to workman's compensa- tion laws of California." The applicant mu#t call for all required ' portions. Cam Yate drawing verseside Signed _ itle: Date: EP MENT USE ONLY Application Accepted by - Dots Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: V �/D/ q m' 93 Prdyt Sed Applicant - Return all copies to: San Joaquin County Public h Ser ices/r^p^ n - dy Healt Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE q CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 1S I4 111EV.f i n er wN I w O l r4 15 �gE. /4/)14 fir"Gf•�3 0 T�r EH 14.20 (f II ti .,