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APPLICATION \ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES \ ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 SCANNED�( P O BOX 2009, STOCKTON, CA 95201 AN PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or Install the work herein described. This application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Heallt,hs S ervices. De p Job Address ,�,�� QAI N> p City Lot Size/Acreage e Owner's Name �`A� t C'*4 b p a^'V� Address a?.!SO Contractor--_A . Address Dade /2d Ai4TMeOP Lice se Phone TYPE OF WELL/PUMP; INEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Cut of Service Well Lf 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 ' ❑ Industrial ❑ Open Bottom � 1,715 Manteca Dia. of Well Excavation Dia, of Well Calling [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications:' I I'I Public I1 Other In Delta Depth of Grout Seal Type of GrouI I I Irrigation —.Approx. Depth 'I I Eastern Surface Soul Insialled by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth - - Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION'tJ DESTRUCTION! 1 (Norsepnc systempermittedif public "war is !`` available within ?00 feet.) Intallation will.serve: Resipenee Commercial_+7Other - Number of living units: Number of bedrooms I - Cheracter of wil to a depth of 3 feet: `Water-table depth SEPTIC TANK ❑ Typa/Mfg Capacity 'No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal y Distance to nearest: Well Foundation Property Lim LEACHING LINE ❑ No. i Length of lines /-0 Total length/size FILTER BED ' Distance to nearest: Well_&=ffef'rFounoation Property Lim _ SEEPAGE PITS 11 Dapth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 canifies 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 mustcallfor I requir o/spyections. Complete drawing on reverse side. /.-+� O7 ` Signed X !f'�/ L�cL�G� Title: .. Date: p �J`y' O_J FOR DEPARTMENT USE ONLY Application Accepted by Date 6— &I — 93 Area d& _ 3 Pit or Grout Inspection by Date Final Inspection by Date 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 INFO AMOUNT DUE AMOUNT REMITTED CC L1,, RECEIVED BY DATE PERMIT NO. sR ta.z.uEv.r„s. SIZ 11.4 �� 1414 � t1 —Drell 93 43 ' ! '( EH txae