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3PPLIC3TION "AN JOAQUIN COU= PUBLIC HFA,TH SERVICES ENVIRONMENTAL HEALTH DIVISION DEC 0 8 1994 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOC%TON, CA 95201 OW-3 ENVIRONMENTAL HEALTH PERMIT SIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) Application is hereby wade to San Joaquin County for a per--it 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 'Jea.lth 3a, ces. w ic �' 1 i t l� j� Job Address C� 1 !V ^R b Qr��(r}4v l'� �t "City Lot Size/Acreage Owner'sName ��CC �t��c�5 �'t0"'^`t Address -2.lOc"ge aj, 1� �ul�5_ � Phone i '�1 Z�6yF' G{4,40 A 32 41 F�'+ ar 2��7 e Z. � �t A,) Contractor ddress _fes .C� Cc n:� C':-4 -1.42 License N0 _S760223_ Phone�SZ-7NS`1 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCT[ O Out of Service Vela 0 PUMP INSTALLATION O SYSTEM REPAIR O i _ {ER O Monitoring Well DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES SD �or�'t OISPO Al FLM PROP. LINE r30 FOUNDATION AGRICULTURE WELL OTHER W L PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIE ATIONS +noYatvie+--4L0•t t-&-r,w •O Open Bottom O Manteca Dia. of Well Excavat Dia. of Well Casing z' C'1 Domestic/Private Gravel Peck Cl Tracy Type of Casing_ L C4 �1v Specifications 1'1 Public f.l Other Delta Depth of Grou eal %0—/Z' Type of Grout CUsu -%& 4 I I Irrigation 2t2 Approx. Depth I I Eastern Surface Se Installed by Repair Work Done L3 Type of Pump H.P. - State Work Done_ Well Destnrction O Well Diameter Sealing Mate al i Depth Depth Filler Ma rlal i Depth TYPE OF' fPTIC WORK: NEW INSTALLATION I I REPAIR/ADO ION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve. idence_ Commercial_ O er Number of living units: bar of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PCT.0 Method of Disposal Distance to nearest: Well Fou ion Property Line LEACHING LINE ❑ No. 6 Length o Ines To ngth/size FILTER BED ❑ Distance to rest: Well Foundation Pro Line SEEPAGE PITS 11 Depth Site Number SUMPS LI Dista to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that I have pre this application and that the work will be done in accordance with San Joaquin county ordinances, state Laws, and rules and re gulations of the Sa Joaquin County Home owned pen a signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any such nner as to become subject to workman's compensation Laws of California." Contractor's hiring or sub-contracting signature certifies the : "I c ty that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa• tion laws o The applicall or sit rpuired inspect ons. Complete dravtiinp oft severap�rida, SWC Title: _ pillsigc�- Gfii(.i L S�' Date.- Z f 7 A Y T� FOR DEPARTMENT USE ONLY Application Accepted by Date Arca 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 [FEE AMOUNT DUE AMOUNT REMITTED CK t CASH RECEIVED BY DATE PERMIT'NO. fM 11N MRV.I/w si EM 1476