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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION to% op"l _� ± ; 445 N SAN JOAQUIN, PHONE (209)468-34201% 11 Ifs P O BOX 2009, STOC%TON, CA 95201 4 " V - PERMIT E%PIRES 1 YEAR FROM DATE ISSUEDOCT 0 9 1992 (Complete in Triplicate) t6r4itillONMENTAL HEALTH Application is here made to San Joaquin Count for �ER!VI T495Y Q9 pp by q y permit to construct and/or install he wor e n b ed. 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. � Job Address 1 •• I 2"�T t�� Cit 1yho � _ LLot�Stize/Acreage Owner's Name �•�t%S l��tir <1 [ �C� ddress E7-lir �� ( ! 1 1 o10SIL1. -1,,;,3 one'��3-'S I• �.tj Contractor 1\�S1VT� Address ( � (-� hl a1 CSCF�LCj� License No _!' Phone - -5 TYPE OF WELL/PUMP! NEW WELL ❑ WELL REPLACEMENT n OESTRUCTION,21�,Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �.O,THHEER'❑ Monitoring well DISTANCE 70 NEAREST: SEPTIC TANK I SEWER LINES 725 DISPOSAL FLD.� PROP. LINE �fL�C r FOUNDATION n AGRICULTURE WELL r`r OTHER WELL-ELL— PITS/SUMPS 1!__� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS :r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f;: Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Pt,L.. Specifications t 4 fSL I'1 Public Other n Delta Depth of Grout Seal 4 Type of Grout I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _ State Work Done_ Well Destruction Well Diameter tip Sealing Material & Depth 1-t :%L/ 7c-,77701 f(_) Depth ��r Filler Material & Depth i)-&k(A_.',,. rrl-0 A L AATl6 k. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo 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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & 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 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 applicca'ntt�mmuusil call_for all r uir dsinslpect. s. Complete drawing on r erre side. ///'7 ,�• Signed _/a[L L /�/2 Title: r C Date: G `� FOR DEPARTIMEd4SE ONLY Application Accepted by Q� Date /y . /2- / 2- Area u� Pit or Grout Inspection by \,t 1 (� Date�I v'�v ' , ,�, Final Inspection by ..L., Date Additional Comments: YV Qees v "' 6O 'L✓, �e'�-KCA llC.� 1 f!� lam' '� Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO rNCASH . EN 13-I4ItIEV.I1x51 Iltp� /r1 lt1•��- (Z -1(,."�� EN tb7e