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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION NOV 10 1993 P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 ENVIRONMENTAL HEALTH PERMIT/SERVICES (Complete in Triplicate) Application is hereby mads to San Joaquin County for a permit to construct and/or install the work herein described. This application Is made in ccapllance vith San Joaquin County ordinance No, 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health services. _ prP tJ aq4- o So- It Job Address r /2 / C City Lot Size/Acreage I At-- Owner's Name � M ., L" Address Phone (32-"- 2_`12_f- ConlractorC � ,A >Address Z3 R- 'r2 RO0 License rio4kiQ _,_Phone 5�7-5 76 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER fX Monitoring well L7 DISTANCE TO NEAREST: SEPTIC TANK IVIA SEWER LINES rC i i/-+ �� t DISPOSAL FLD.� PROP. LINE L FOUNDATION _LL— AGRICULTURE WELL OTHER WELLLC r PITS/SUMPS 112Z,4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 1) Open Bottom 0 Manteca Die. of Well Excavation Dia. of Well Casing f1 XDomestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications M Public KOiher O Delta Depth of Grout Seal �ivz,a,aCOr _— Type of GroutCJ _(°. Irtioation 1? Approx. Depth 0 Eastern Surface Soul Installed by CO3t1"i12ACibr2 Repair Work Done ❑ Type of Pump H.P. State Work Done _ Wall Destruction © Wed Diameter Sealing Material i Depth Oeplh Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION C1 (No 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 snit to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Q No. i Length of lines Total length/size FILTER BED n Distance to nearest: Welt Foundation _ Property Line SEEPAGE PITS 11 Depth Sire _ Number SUMPS L'I Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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 canify that in the performance of the work for which this permit is issued, l 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 Californlo." The applicant 9 u c I to a requir tions. Complete drawing on reverse side. I., Signed Titls:/%rgr"r __) Gus,cAs C,� Date: t/!7 3 FOR DEPARTMENT USE ONLY -/ j,�"1 t Application Accepted by Date �iZAY Area�'D Pit or Grout Inspection by Date Final Inspection by Date L 1 Additional Commantar Applicaot - Return an copies tog SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN. P O.BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMirrED INFO all, Ay CASH AECErVED 8Y DfATE PERMtT'NO. 04 I3•71 to EV.7�N 51 T+l d Pj/ iI//� +�