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APPLICATIONjg�r/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION MAR 2 3 1993 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PE0I`0bSEFtICES (Complete in Triplicate) Se' ~ c aSI-VO , 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. ry ct—1 e-ti-J- 4o 225Job Address Z02� 13&,1 City - Lot Size/Acreage Owners Name Akb jit'j i--L t-) Address �-O. Qo,v- �$I S G M4��o r C?c. '1410 Phone it 0--5-71- Contractors kl�< 1�11� Address P013ocm,Likz611C 61')S -I,S License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER Cl Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES >504--- DISPOSAL FLD. PROP. LINE —30" FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll 1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10" (1 i7 Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_PUC- SL�. L40 Specifications PbC r I") Public Cl ether Delta(S} d,(16,) Depth of Grout Seal f Type of Grout I 1 Irrigation 30L.Approx. Depth I I Eastern Surface Seal Installed by JA! `s Repair Work Done 0 Type of Pump H.P. State ark Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth ' 1 Depther Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION o se is system rmitted if public sewer is vailabl within 200 f t.) Installation will serve: Residence �b.dr alNumber of living units: Num er f ms Character of soil to a dept 3 feet: Water table depth SEPTIC TANK ❑ ype fg C pacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Di tance to nearest: Well F ndation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 workmen'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 applican must call for all required ins coons. Complete dr ipg,p rave se fide. NN � j! I -t Signed X /r 1 0 ✓.n Title: 97 Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT'NO. EH 1344(REV.I/n sr EH 11.20