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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION FEB 12 1992 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERWISER'V B (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 is rade In compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Countyc Health Services. w- t 7� :5-73Z 1 "� .Af 2G d Job Address _,, Ae+ o �+r 1 r� City StaLR4014 Lot Size/Acreage u 9 QCl`4t / 'p // /� �( 314 P C31`f) S7 7- Owner's Name,Lx N�leb(SGIr B AS04 l 0&0,2 �S Address J Bbl.St�+ PlAce, �•Lav /F A440� Phone rte' G M u t�NJ� t" CGA[o,4 CA q�� Contractore-An010 -TAC Address D Be rt CA 15i909w License No. Phone-61L-2-397 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O 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 O Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private (Gravel Pack ❑ Tracy Type of Casing 5(N.yo P✓e- Specifications Il Public 1:1 Other n Delta Depth of Grout Seal Type of Grout S itil 1 1 Irrioation t�:—&Approx. Depth 1 I Eastern Surface Seal Installed by 4/q_ A Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material 6 Depth Depth Filler Material 6 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 r Commercial_ Other Number of living units: Number of bedrooms Character of sop to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. i1 Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number �} SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O °9 I hereby certify that 1 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applic ust,ta or-all rewired inspections. Complete drawing on verse side j B Q7/ Signed Title: A kf Date: l 7 FOR DEPARTMENT USE ONLY a 9 Application Accepted by Date ` Area Pit or Grout Inspection by Date7 p2-Final Inspection by Date �3 Z Additional Commonts: — Applicant - Return all cop es to: San Joaquin County Public Health Services / Environmental Health Permit/Services 1 5 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT'N0. INFO EM I3* 24 I11EV.1 I N 51 �'} F7 Z-a6 EH 1416