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r APPL•IC.4TTON SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 PAYMENT P 0 BOX 2009, STOCKTON, CA 95201 R ' Fr PERMIT =IRES 1 YEAR FROM DATE ISSUED AUG 0 71997 (Complete in Triplicate) Application Is hereby made,to San Joaquin County for a per t to construct and/or install the work herein described. This application Se �gAtl$ S�Ntf�,th San Joaquin Co y Ordi ce No. S49 and 1862 and the Rules and Regulations of San Joaquin county me A114 M., I$135 1 GA qq alq H Y�p N Mdr na 4HT Job Address V T $ } /a+.o4 Fer P E:f �I(• City -5�e k'1'ovs Lot size/Acreage (7/acj- 010-lO�llf�o 1 1 1 qri 1'703`{ Owner's Name Mr. �a✓;OS M, Mt r}lk Address Phone 5Pfec'FrtAN+ FXpbrA*-;v. /A.w4e✓ �.gperV.s ia� C_ Contractor oT 6or ✓ e`ar�G. Tec G,Address A36 W wa,+. 5�1-1y'�icense No. h 1A ]6Q+ Phone X65 -g�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ . OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ well INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,r n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Cie. of Well Casing EI Domestic/Private >j Gravel Pack ❑ Tracy Type of Casing_ PVC Specifications I'I Public 17 Other ><Delta Depth of Grout Seal 0-3'01 7 'llfq I Type of Grout i3a"4' Ce+er I I Irrigation _Approx. Depth I I Eastern Surface Saul Installed by Soee+-AA+^ Repair Work Done fJ Type of Pump H.P. State Work gone_C Oel Well Destruction ❑ Well Diameter rl Sealing Material 6 Depth Rrz4k. Ge»•e" Depth aD f }v i0/Filler Material i Depth 0✓nve 1 Pc c l — *i 3 /4-,- , TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public suwer.is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of and to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 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 Home owner or ficensed 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 cenify 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 applica st call for all required iwnspgctions. Complete drawing on reverse side. ,(� -�_ _�-,,T` c2 �7I Signed K_! '�'^� _ Title: /✓l�.lMa/ 'rF-�'� t-^�'^r l Date: o — 4 I'II ,z' FOR DEPARTMENT USE ONLY Application Accepted by ��n o• y9l'�l� 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 AMOUNT DUE AMOUNT REMITTED CKASH RECEIVED BY DATE PERMIT'NO. IC NFO . E11'2x IREV. /xai S EM tx•ld