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APPLICATION �+p # � ��► SAN JOAQUIN COUNTY PUBLIC HEAL JH%��tR j'JCES ENVIRONMENTAL HEALTH DIV. ��f}� APR O 4 1594 445 N SAN JOAQUIN, PHONE (209) 20''FF 20 P O BOX 2009, STOC%TON, C 99�U ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM PERMITISERVICES (Complete in Triplicat Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �� 1 �,,,, �1,/ ' - a Job Address �S � 450ate'"tT,r ' :4 City Lot Size/Acreage Owner's Namaf//,L 'rte W_44'+"'d� Address Phone R. Contra Tr nBl.4�g� JPs�.�ri� AddreJsQ�� Phil -Cr 61 Dcwolicense Nom-.� d"_ Phon � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ / DESTRUCTION ❑ Out of Service Well ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER O 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 Ll Industrial ❑ Open Bottom Cl Manteca Die. of Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — ['I Public ❑ Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Sudace Seal Installed by Repair Work Done Type of Pump 2 s.lam. H.P. StatelWork Done Well Destruction ❑ Well Diameter Sealing Material i Depth 4u 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 A 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 Propertypolk r* LEACHING LINE ❑ No. 6 Length of lines Total length/si AI FILTER BED ❑ Distance to nearest: Well Foundation Pro e L a SSNJOJOfilm@ . VViJLIC SEEPAGE PITS 11 Depth Size Nt�r "�^+ SUMPS LI Distance to nearest: Well Foundation Prop, HEA!Tu^::7�IgN DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stateIsignature .� 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, employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontractincertifies 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 p tion laws of California." The applicantryust I required in tions. Complete drawing on rev rse side. Signed X ( .dN��. �4j'� Title: -- Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area a. Pit or Grout Impaction by Date Final Inspection by Date Aril Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ... ^ \ Environmental Health Permit/Services Oy(/// 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE q UNT DUE AMOUNT REMITTED CK RECEIVED BY AT PERMIT'NO. INFO ' EH tY24(REV. EN 1421