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APPLICATION a SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE R""CPIKU ENVIRONMENTAL HEALTH DIVISION MAY 18 1993 445 N SAN JOAQUIN, PHONE (209)46$-34 P O BOX 2009, STOCKTON, CA 95201 1VIRONMENTAL HEALTH ,. PERMIT EXPIRES I YEAR FROM DATE ISSUEDHERMIT/SERVICES (Complete in Triplicate) A. _ } Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This a application is made in compliance with Ran Joaquin County Ordinance No. 549 and 1$62 and the Rules nd'Regulatione of San Joaquin County Public Health Services. IL Job Address City Lot Size/Acreage OF Owner's Name - Address _ Phone r �yt� Contract Addre r. 34,ense q. 1 Phan TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1-.1 Out of Service Well ❑ ! PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ 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 CnIndust ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Wail Casing ""tie ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications l'1 Public i-1 Other 11 Delta Depth of Grout Seal Type of Grout-- I routI i Irrigation �Approx. Depth I I Eastern Surface Soul Installed by " l Repair Work pone 1? Type of Pump �� H.P. State Work Done Well Destruction, . ❑ Well Diameter Sealing Material & Depth Depth — Filler Material & Depth, I TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is v available within 200 feet.) 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. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ s Method o1 Disposal Distance to nearest: Well _ Foundation Property Line LEACHING LINE_. r Cl No. &Length of lines Total length/size FILTER BED Ci Distance to newest:..._WeltFoundation " Property Line 1 SEEPAGE PITS It Depth SizeNumber I SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 t 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 taws 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 applicant must I required ins WC 10 Complete drawing o arse side. r Signed X. Title: Date: 3- ?3 , PARTMENT USE ONLY f riri of Application Accepted by Date Area 2., Pit or Grout Inspection by Date Final Inspection b p Y Date_ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Bealth Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO4 I r EH 1 3"24 TREY. /n 51 �! 8 9, _^• ~