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I APPLICATION # $SAN JOAQUIN COUNTY ,PUBLIC HEALTH SERVICES - `'" ENVIRONMENTAL HEALTH DIVISION / - X445 N SAN JOAQUIN; PHONE (209)468-3420 . , P O 'BOX 2009; STOCKTON, CA 95201 PERMIT EgPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) k Application— is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This l application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regula£fons of San Joaquin County Public Health Services. Job Address A,14251mzr CityT.i nr en _ Lot Size/Acreage r,{] l Owner's Name Dick S-eekat7 . Address 40nr, AT-�PezziT•a�Q _ Phone / Contractor UrVi ance T]ri 1 1 QrS00MY3, _ P-0— Rox A . T.i nrl�n License No. Phone TYPE OF WELLIPUMP: NEW WELL a WELL REPLACEMENT n OESTRUCTIO t of Service We31 ❑ PUMP INSTALLATION [k SYSTEM REPAIR ❑ 0TH Monitoring Well, 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 15 FOUNDATION AGRICUL•4URE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM ARE,g CONSTRUCTION SPECIFICATIONS n Industrial f�j Open Bottom ❑ Manteca -: j Dia. of Well Excavation Dia. of Well Casing (1 Domestic/Private Cl Gravel Pack 0 Tracy ! Type of Casing_ StPP1., Specifications .a50 I'I Public 1.1 Othe�4� �zb� n Delta ff; --.,Depth of Grout Seal S0 _ Type of Grout. .S'pmPn � y .13t Irrigation 4UApprox, Depth i I Eastern }- Su ca Seal Installed by C Repair Work Done U Type of Pump tllrb H11P State Work Done l • I n Weil Destruction Jk Well Diameter 1 2 Se Ing ,erial 6 Depths n t , , f P `-' 59eemea l •Depth Filler Material & Depthq;4 n ri�L,r I n a TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I-INo septic system p&mitred if public sewer is r' = available within 200 feet.l Install n a`rili'"rri e:; Residence, Commercial Other V } Number of living units: Number-of-bedlrooms f T` f Character of soil to a depth of 3 feet: ,WataTµtable depth o �. �. SEPTIC TANK. D Type/Mfg �� Capacity y Nd�;Coillpartments PKG. TREATMENT PLT. 0 /' 'Method of Disposal, } Distance to nearest: Well' Foundation / Property Line 4 � I ,,LEACHING LINE 0 No. $ Length of lines Total length/sire FILTER BED ❑ Distance to nearest: Well Foundation Property Line .tl SEEPAGE PITS -1 I Depth Sire Number SUMPS 0 Distance to nearest: Well oundation Property Line --DISPOSAL-PONDS B - } 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 cenifies.the following: "I certify that in the performance of the work for which this permit is issued, l 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 1` 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 ifornla." The i plicant gnus all f r a requir inspections. Complete drawing on reverse side. ti Signed Title: Corm-_ Secretary Date: 1129/92 USE ONLY Application Accepted by Date ^,3 11�Z Area 3,4 Pit orrou apection,b'y Data� 0- _ Final Inspection by ` Date Additional Comments:' tef%�_ AaL0644— t1 G Applicant - Return all copies to: San Joaquin County Public Health Services f Environmental Health Permit Services 445 N San Joagtain, P p Box 2009, Stkn, CA 95201 I/ FEE AMOUNT DUE AMOUNT REMIT-TEDC INFD CASHK RECEIVED 8Y DATE PERMiT NO. �