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APPLICATION FOR PERMIT ' ] SAN J QQUIN COUNTY',P�UBLIC HEALTH ICES V12 �d l � ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,,—PHONE (209)468-3420 e P O BOX 2009,. STOCXTON, CA 95201 MAY 3 , t995 g PERMIT EPIRES 1 YEAR FROM DATE ISSUED HLTH (Complete 'in Triplicate) ( 4 . RMT/SERVICE 1 Application is hereby mnde.to San Joaquin County for a permit to construct and/or Iner ll. the work herein 'described.,:"rhi6 application is made in compliance with San Joaquin County Ordinance No. 549 and 1862'and the Rules and Regulations of Sea Joaquin County Public Nes.1th Services. 6 t � ` " a z Job Address City r Lot Si zc/Acreage Owner's Name ri G Address13Z E r c. ' (Phone 2'07) 9 —083 6 l Q- sctoH z2 aq)i{65 7 Z Contractor c L"K �2 2dress 92. r License N.0,5122.6-3—Phone TYPE OF WE L/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out or Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 'r" OTHER ❑ No Well ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES'. DISPOSAL FLD-� PROP. LIfVE L FOUNDATION AGRICULTURJ WELL �� OTHER:WELLILC� PITS/SU =J MPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t M Industrial ❑ Open Bottom •❑ Manteca Dia. of Well Excavatio Dia. of Well Casing `-1 Domestic/Private ❑ Gravel Pack *51- Tracy Type of Casing �VL __ Specifications f'1 Public Other i f"1 Dena J7epth of Grout Seal I;vl+ - Type of Grourq - I l 1rriUatian r Y �Approx. Depth `I 1 Eastern Surface Seal Installed by_ _ Repair Work Done 0 Type of Pump H.P.' Stats Work Done _ Well Destruction ❑ Well, Diameter Sea 3itig Itlateria.l i Depth Depth Fi11er Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f I DESTRUCTION I I Wo septic system permitted if public sewer is available within 200 feet.} Installation will serve: Residence— Commercial— Other ° Number of living units: Number of bedrooms'7� t Character of soli to a depth of 3 feet: Water table,depth SEPTIC TANK. ❑ Typoimfg ` Capacity :moo No:Compartments PKG. TREATMENT PLT. ❑ Method of Disposal- Dimanee to nearest:-w->F Well Foundation Pio periy'Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well "� .-Foundation Property Line SEEPAGE PITS It Depth -Size NumberTz SUMPS la Distance to nearest: Weil' :Foundation Property Line DISPOSAL PONDS ❑ t t> '► ' I 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 Horne owner or licensed agent's signature certifies the following: "'l cattily that in the performance of the work for which this permit is issued. I shall not employ any person in such manner so to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "1 dirtily that in the performance of the work for which this permit is issued. I shall employ persomsa ns subject to workman's copen -.' tion laws Ma. :h r The appl nt rttus call for allequ ed in f . Compteta.drawinq on i�sv�er/Jse/Jside. _ /n Signed "Y Title: Date: DEPARTMENT USE ONLY !! Application Accepted by_ 1 Data J�' A,..-- Pit or Grout Inspection by Date F4nsl Inspection by Date Additional Commants:. + Applicant - Return all copies to: San.Joaquin County,:Pubiic Health Services onvirommental Health Permit/Services 445 N San Joaquin, 'P O Box 2009, Stkn, CA 95201 FEE INFO AMOU�N/+TM ')DUE AMOUNT REMITTED CASH RECEIVED By }OATS PERMIT NO. EN 1124(REV.„m s) - EH 1440 1 l