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APPLICATION U SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL :HEALTH D I V I S ION jy�� 445 N SAN JOAQUIN, PHONE (209)468-3 +�� P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE issuEDJAN 1 6 1992 (Complete in Triplicate) �p��}� Application is hereby made.to San Joaquin County for a permit to construct and/or instal � e"e��Abed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and theQ Ygtions of San Joaquin County Public Health Services. �J Job Address `Z ge S _ �a1n S� - City Lot Size/Acreage 7 %/ e Owner's Name C�r+f:S �. JQC-K Address \ZCV S, hW%IN Sk S� Phone "Z %12?3 5M,r1sa&611 :rale y Contractor Address License No. ' hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL•REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER 14onito;ing well O DISTANCE TO NEAREST: SEPTIC TANK ISCt� SEWER LINES 7 �SC� DISPOSAL FLD.d�'PROP. LINE FOUNDATION 7ZS 1, AGRICULTURE WELLZ MIf OTHER WSLLI� PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pacit7 0 Tracy Type of Casing_ NQ Specifications I'1 Public D4.Other 50'% � Delta Depth of Grout Seal g,11 Type of GroutzebAda; I I Irrigation 30±Approx.x.�Oepth+ I I Eastern Surface Seal Installed by S�Jft.a Repair Work Done v Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/AOOITION 1 I DESTRUCTION I 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 sod to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ a Method of Disposal Distance to nearest: Well Foundation Property Line e LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 subcontracting signature certifies the following:"I certify that in the performance of the work!or which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requir ins tans. Complete drawing on averse so e. for r HOWw%. Signed Title: Zlf '- jf ` FOR DEPARTMENT USE ONLY Application Accepted by Date ( Area Pit or Grout Inspection by Data _Z- Final Inspection by Date Additional Comments: i Applicant - Return all copies to: San oaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO . EM 13.24(REV.I/It51 /� � a � l_/U +/ 9 '!/�/ EM u•2e CC