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' APPLICATION PAYMENT b SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED ENVIRONMENTAL HEALTH DIVISION 1g 1993 445 N SAN JOAQUIN, PHONE (209)468-3420 SAN Tv P O BOX 2009, STOCKTON, CA 95201 SAN 10p AL I E�IGES10N PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUgL1CNTA�HEA�TND (Complete in Triplicate) ENVI�ONMEN Application is hereby msde.to San Joaquin County for a permit to construct and/or install the work herein described. This application is code in compliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address -{ City Lot Si ze/Acreage I(o U3o -b0 ST Owner's Name � 'Y 1 �t1,��1�IC3Y1 Address C{7]Cl \4 0 N1Y�C�Y ��(l\I Phone Contractor �O Address E License No.21ai of Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O aKonitor nB Yells d 4 SC`s\ bor�r\QS P DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' >5O' DISPOggppL FLD. PROP. LINE >30' J > DDU' 'Hcrt�xiv FOUNDATION �� AGRICULTURE WELL �_ O�HER`'11VELL,S PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ri Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation /O" Dia. of Wen Casing T<Domestie/Private O Gravel Pack ❑ Tracy Type of Casing 19VC 5dlwd• L/U Specifications ,U/ I'I Public Cl Other fl Delta Depth of Grout Seal-'I' n we 1150 bon'N5)Type of Grout✓l9A CCA)g 1� I I Irrigation ($'+'o�Approx. Depth I I Eastern Surface Soul Installed by 4r l t1 e r� O Y"r 'Res(�A, Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I fNo septic system permitted it public sower is available within 200 feet.) Installation will serve: Residence_ Cortrnercial_ Other Number of living units: Number of bedrooms Character of sol 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/sue FILTER BED O Distance to nearest Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to n"Festo Wen Foundation Property Line DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stab laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature mortifies the following: "I certify that In the performance of the work for which this permit is issued,1 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:"1 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 ap it call for all requir inspitctiorm. Complete drawing on reverse side. - Signed Title: 92 • Date FOR DEPARTMENT USE ONLY Application Accepted by Date �� 7?J Area Pit or Grout Inspection by Date Final Inapsct on by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Z9/_f� Environmental Health Permit/Services y I O 445 N San Joaquin, P O Box 2009, Stka, CA 95201 ST FEE INFO AMOUNT DUE AMOUNT REMITTED CASH ECENEO SY DATE PERMrT'No. • EH t7-74 II1EV.I/AS) 8Q, ' �j,6 t� (l�9 2-5-9 3 93-OI9�' EH 11.7!