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- .7 i APPLICATION FOR PSRYIT ✓ V SAN QUIN COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISION JUL 1 6 1993 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) Application Is hereby made to Sen 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. ,../�/r { 7 Job Address /( 900 S'c,-;7� I ( t.r-/Lr1 /2�/ 1� City Zfk-:7 1� Lot Size/Acreage/41!- T 20-C[//^Qstf Owner's Name nrcul,SCj t -IJdSS /�1✓Gf M6; ddress /ravJ / (qr�4� � Phoney 5 - 7 , r y � Q // 3/6� U Contracts O r Oft Yr /! Address t:cC[[�tro-l. ( License No. Phone 6�-31? TYPE OF WELLl PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well. -b( DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATION ❑ Industrial ❑ O pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing /Vl Cl Domestic/Private 0I Pack ❑ Tracy Type of CasingSC6eK/"- 40 /Or/'G Specifications I'1 Public fl Other fl Delta Depth of Grout Seal �l�0 z4rz:% Type of Grout-�� I I Irrigation 7 l�Appfoa. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Stats Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth r /r70hl1'1I`0t`T Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOPTION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 210 fest.) Installation with ssrw: Residence_ Commercial _ Other Number of living units: _ Number of bedrooms Character of and to a depth of 3 foot: 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. 6 Length of lines Total length/size FILTER BED ❑ Distance to neetasC Well Foundation Property Lina SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Wall Foundation Property Line DISPOSAL PONDS ❑ 1 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 rules and regulations of the San Joaquin County Home owner or licensed agent's signature cortifies the following: "I certity 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 folbwirp: '9 certity that in the performance of the work for which this permit is issued, I shall employ Persons subject to workman's compenoo- tion laws of California." The applicant must or M r ked it tans. Co IaIMe drawing on reverse STitle: Z 1..r.— Rined Ii�`/y-� Date: `- ^ ,g FOR OEeARTMENT USE ONLY Application Accepted by /✓/Y/ y�e—�L��1�( � Date 7 7—, Area Pit or Grout htepection by Date Final Inspection by Date Additional Commence: San Applicant - Return all copies to: 445 ronmental Heay P Peic rmitealth/Oery Stkn Services 95201 Environmental Health Permit/Services t/Services FEE AMOUNT DUE AMOUNT REMITTED CK INFO �A (7/� CASH RECEIVED ;BY PATE PERMIT NO, . EM 13.14 MEV.11 m a, W -- C-1 �,�_ �- '"'i _,1 I EM U.L 'J i f.>d /f � Ll �3 �3��