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r APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1q ?-J"�y 445 N SAN JOAQUIN, PHONE (209)468-3420 ��Y eIV7- L O -BOX-2009, -STOCKTON. CA-9_5201—_� RECE,vie® PERMIT EXPIRES Z YEAR FROM DATE ISSUED APR 19 1993 (Complete in Triplicate) PUBLIC U � H ALT CO��{11N�flt�Yr� Application is hereby made,to'San Joaquin County for a permit to construct and/or inetallthje` bg� iplH� � This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regu Joaquin County Public Health Services. Job Address d *d L �C} City sVcKra/i Lot Size/Acreage a),,AJ I? x,) FARC:,c1� Owner's Name LU C 7 Address c�?/7"2 VAL'Lev/,C 11Z,4 �T 7-/0 hone .su;rC- y W ,1stt VI c Le, T,v 3•->.;?;Z Contractor�C S Ad6ress��- -�1�rx_��.��' 7K�License No..3 g/�/rte 9`I Phone YPE Of WELL/PUMP: NEW WELL ❑ WELL REPLA MENT .. �:1 DESTRUCTipN C7 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �� 7 ER Monitoring Well C3 pISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES 1 DISPOSAL FLD. OP. LINE .- FOUNDATION AGRICULTURE VVELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing EI Domestic/Private ❑ Gravel Pack E] Tracy Type of Casing_ Specifications Il Public C7 Other 1-1 Delta Depth of Grout Seal Type of Grout t I'trrigation _ApproK. Depth I I Eastern Surface Saul Installed by Repair Work Done U Type of Pump H.P. _. State Work Done — Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material i Depth 'TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) �+ Installation will serve: Residence_ Commercial_ Other Numberofliving-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, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Welt Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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 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 California." applicant must ca for all quired inspections. Complete drawing on reverse side. ,The gned XA Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by � b �f,G�� Date Area Pit or Grout Inspection by / Date-.Final Inspection by _L �� Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health ,Permit/Services �t45 N San Joaquin, P O Box 2009 2909, Stkn, CA 95201 11 INFO AMOUNT DUE REMITTED I CAS Ft RECEIVED /BY DATE Q PE7R.,MrinTf'/N/0r�.#J ff*� • EN 1{•7e tREV.tinSs +� Vi��. Cl y �f �v -7