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APPLICATION SAWN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RpsaytJ ENVIRONBENTAL 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 (Complete in Triplicate) ENVIRONMENTAL HEALTH Application in hereby made PERMIT/SERVICES to San Joaquin County for a permit to construct and/or install the work herein described. This application is made 1n compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /9PN r?C(-Z(a t:—/Q Job Address 39 0 Me-+ro DN;f- City ee1<*J4 Lot Size/Acreage '� 7 4*CSS Owner's Name A,') y` ,UGV-0 S77- KSC4 C2w--AKI�Address NS -e S .4094 �d�j��dPhone 6- K E►�a wJa+er }� .t Contractor E rts+ Address OS !«"r t License No.YAY.?Y� Phone-62L-2V-7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION O Out of Service well O PUMP INSTALLATION O SYSTEM REPAIR ❑ 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 Z 0 Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing F1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S&4- go f VC _ Specifications i1 Public EI Other n Delta Depth of Grout Seal Type of Grout eot, ,*,Shj 1 1 Irrigation q0—Approx. Depth I I Eastern Surface Seal Installed by G h4-Vt�y Repair Work Done U Typo of Pump H.P. State Work one_ Well Destruction O Well Diameter Sealing Material b Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is (� available within 200 feet.) \J 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.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b 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 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 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 applies 41t 11 for all required inspections. Complete drawing on verse silo. Signed X Title: M-1 e Or Date: r, J A Z FOR DEPARTMENT USE ONLY !/ Application Accepted by Date L Area Pit or Grout Inopoction by Date-_•ao Final Inspection by Date a S _ �yrZ Additional Comments: r_ Applicant - Return all cop s to: San Joaquin County Public Health Services Environmental Health Permit/Services Q ✓1 �Y 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 L J IFEEO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT'N0. • EH 13.74(REV.1/w5, 1 --0301 EH 14-23 (/