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APPLICATION *' -, J E. SAN JOAQUIN COUNTY PUBLIC HEALTH SE VIQf ii ENVIRONMENTAL HEALTH DIVISION � '• 445 N SAN JOAQUIN, PHONE (209)468— � # 1 :i P 0 BOX 2009, STOCKTON, CA 9520 PERMIT EXPIRES 1 YEAR FROM DATE IS IIEI7" J (Complete in Triplicate) 11r1V # Application Is hereby made,to San Joaquin County for a permit to construct and/or insall the work ere n escr e s 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 15773' . 6-.- Lo"4,6 7-R'cE QD City �'`� Lot Size/Acreage //0 �G _ I Owner's Name P�7 vC Address Phone Contractor rGie.- D, A.,IoF. r..f ""AC64ddress 22- •% lhvgTd.v 4,N Gu 0 /acs'Y 1 License No. G/ G -370�Phone 3 7 , TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I1 DESTRUCTION ❑ Out of Service Nell a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation pia. of Well Casing f.l Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing_._ Specifications I F) Public 14.Other f7 Delia Depth of Grout Seal T i P Type of Grout I I Irrigation rr Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L1 Type of Pump H.P. _ State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth i TYPE OF SEPTIC WORK: NEW INSTA�7LLATIO REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is Ll �C/L[.ua ¢��v-J -p5S3-5 SGG A774, a ailable within 200 lest.) t Installation will serve: Residence— Commercial_ Other J? Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 !jType/Mfg No. Compartments PKG, TREATMENT PLT. ❑ ; /��fc Method of Disposal `Distance to nearest: Properly Line PA PAENT LEACHING UNE ❑ `No. & Length of lines otal length/size FILTER BED f_l "Distance to nearest: ��a?�' Properly Line __AUG ,7 1994 I 1111 SEEPAGE PITS 11 :Depth Number �' I�VICR SUMPS Ll Distance to nearest. PID Property HEALTH DIMON f 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, slate laws, and rules and regulations of the San Joaquin County 1 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 Jl employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature cenifies 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 applicant mus for all requir ' spections. Complete drawing on reverse side. Signed X Title: _ / � � T Date: 7 A �i FOR DEPARTMENT USE ONLY -7 hl_� Application Accepted by --- __ Date Area �y Pit or Grout Inspection by Date Final Inspection by Dated I` Additional Comments: k Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P D Box 2009, Stkn, CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. If INFO CASH z Er+ 13zr~V riRei EN t42e