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I1)�r s��.; � APPLICATION FOR PERMIT IV\/� 1L�� JJ,IIIWWIIIJ111 SAN tUI N COUNTY PUBLIC HEALTH IERVICES lliq ENVIRONMENTAL HEALTH DIVISION JUL 16 1.993 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOC%TON, CA 95201 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIUSERVICES (Complete in Triplicate) 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. //90 o se.,� K / �C City `�'/. � Job Address 'n( // £r is°I / � Lot Size/Acreage QCI'e<tJ Owner's Name dr1f1s�'Cas C Tifr (& dd,ess /r 8 aZ1 --T H,Lf-A-- ' reLPhoneme - ��TT /' ('v/s-) Contractor�� ""' r 1-r!!// Address -� ft License No. 3/0 Phone-LC--5- honeC- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well LI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well X DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ /I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION !/ r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing /11 ❑ Domestic/Private KGravel Peck ❑ Tracy Type of Casing SC�1"A— ofO 10V - Specifications F1 Public (-,In Other fl Delta Depth of Grout Seal ' ll� m'a'r Type of Grout y� ~ I I Irrigation 1,W-Approx.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Dore U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material a Depth Depth Tiller Material a Depth ') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I lNoseptic system permitted it public sewer is h available within 200 feel.) V ave Installation will sone: Residence_ Commercial_ Other O Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Properly Line LEACHING LINE Ll No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lina SEEPAGE PITS 11 Depth Sire Number A SUMPS LI Distance to nearest: Well Foundation Property Line 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, state laws, and rubs and regulations of the San Joaquin County Home owner or licensed agent's signature canifies 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'a hiring or subcontracting signatufs\, certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's componsi [}\(,\y' tion laws of California." The applicant must or at r ired i tions. Coqjpiate drawing on rover" sioil�-� Al Signed Title: %�� "`mss / Date: ' FOR DEPARTMENT USE ONLY Application Accepted by ' ,� %� Date Area Pit or Grout Inspection by /r L � Date B � Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services 5 Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK If RECEIVED BY DATE PERMITNO. INFO .�? .q[ iCAASH —J +p 12 /)7 1/ . EH 1724 IREV.i r x si 1l `- -- `�(' 3� °`J f !� —M C: _ / G' !J (`J EH tx m