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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 FEB 12 1992 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EMARONMENTALHEAM (Complete in Triplicate) PERMIT/SERVICES 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. p Road / ckloa7 Lot Size/Acre a �G C Job Address 37.3� Alr�.>ti► 11 DQ d City 88 7 4 �s A L /� , rS+ iS a 43111 (-?/i i6� Owner's Name A" ek,;ei- ILTZi" ��e ddress 1 504 P1A.C�•_�� Phone &14014 w P` �- yDS7 iPb+.t Cit a a.&94 Contractor o It -l- �- Address Cone-ed , CA Q�/S o License No. •3 3 Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O 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 SPECIFI&ATIONS Io Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing Z El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casings .y0 P✓c Specifications Il Public Cl Other n Delta Depth of Grout Seal Type of GroutC 1r,"e-.,4- &A-1 I I Irrigation Ak %App(ox. Depth I I Eastern Surface Soul Installed by cz .b Repair Work Done U Type of Pump H.P. _ State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 hereby certify that I have prepared this application and that the work wili 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, 1 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 pelormance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applican must I for all r quired inspections. Complete drawing on rgyerle side. Signed X Title: fV f-e Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area .31L Pit or Grout Inspection by Date 7i Final Inspection by �� Data Additional Comments: '5a 3 &�, / n .7.&) r 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 -t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVE9 BY DATE PERMIT*NO. INFO CASH • EN 17-24111EV.1/RS) J �G/ L EM 14.21 01 . �YYG_ V