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L APPLICATION FOR PERMIT i, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.' ENVIROHMENTAL tEALTa DIVISION NOV 10 1993 P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 ENVIRONMENTAL HEALTH PEBNI3' FLUXRES 1. YEAR F_ R09 ]SATE SSUED PERMIT/SERVICES (Complete in Triplicate) Application is hereby made to Sao Joaquin County for a permit to construct and/or Install the work herein described. This applicitiioo is —4e in compliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health services. QP4 ORS-ps d 1/ I. Job Address �Z/J �/L ; ol111G City72 GrZZ1,d)— Lot Size/Acreage f Au Owner's(Name V0aM 1'u& ---,•— Address '344q L04-6 ViEld 01? n Phone 62--- 2fi2-f` I Contractori �! 1 WAr2i Address ZS131?1 OCLZ. ROAQ /lr22EQi0 License N 70—Phone�3l"' V6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER S monitoring Well Ll DISTANCE TO NEAREST: SEPTIC TANK IV« SEWER LINES 100 DISPOSAL FLO. �/-1 PROP, LINE I. FOUNDATION AGRICULTURE WELL &� OTHER WELL PITS/SUMPS r�'g INTENbEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing {1 &,Dom's6c/Private O Gravel Pack C7 Tracy Type of Casing Specifications M Public (]�.O�ther IZ ❑ Delta Depth of Grout Seal r&c Or Type of Grout ❑ IrriUatio;n �Approx. Depth ❑ Eastern SurtaCe Saul Installed by Cr7�+i��jbrZ Repair Work Done Q Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth 711ler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION Cl 4No 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 soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 1i - C1 Distance to nearest: Well Foundation Property Line DISPOSAL'PONOS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, stale laws, and (vias and r4gufations 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 subcontracting signature certifies the following:-I Certify that in the pertormance of the work for which this permit is issued, l shall employ persona subject to workman's compensa• tlon laws of California." The applican u c to requir prions. Complete drawing on reverse side, Signed Titla:� -rGsc ld4J�?r;�dr_[� Data: S moi' 3 FOR DEPARTMENT USE ONLY Application'Accspied by Data It h ZATArea`' Pit or Grout Inspection by Date Fina! Inspection by - Date u Additional Comments: ' t T Applicant:- Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 H SAN JOAQUIN. P 0 BOX 2006, STOCXTON, CA 65201 FEE INFO AMOUNT CK t pUE AMOUNT REMITTED CASH RECEIVED by DATE PERMIT•NO, o �f IN 1)•14Illev,lull FH -.4-20I"