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APPLICATION FOR PERLIT� SAN JOAQUIN COQNTy pURLlC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION JUL i 6 1993 445 N SAN JOAQUIN, PHONE (209)468-3420 - P 0 BO% 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH PERMIT/SERVICES PERMIT EXPIRES 1 MR FROM DATE ISSUED (Complete in Triplicate) APP21CAtioa is hereby eros to Ben Joaquin County for a permit to construct and/or install the wrk hereto described. :his Joaquin Con 1• meds ie ectapllmce with San Joaquin County Ordinance No. 549 end 1862 and the Rules and Regulations of Sm Joaquin County Public Health services. // Q o /� Job Address ///n(r/ 0 ��r++'t-� 'Ir " /d� {� City[1� Lot,'I Size/Acreage `�'l_ 7 �2Qc,-� Owner's Noma J�50LAw 1—Crnr r2f✓Ntw}, /�D j / L R/1q—L ddress Phone ' ate_ // v Contractor �� IOr` I-* r /lddress i t License No. q-?16,0 phone C 6'S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Well O f PUMP INSTALLATION ❑ SYSTEM REPAIR O 'OTHER ❑ Monitoring well bI DISTANCE 70 NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD._I PROP. LINE __ JN4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO I U Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation J?' Din. /l ^� ❑ Domenic/Private Dia. of Wall Casing M �`Gavef Peck ❑ Tracy Type of Casing JC/jgk/Z.q0 /Oj/'C. Specifications ! I"I Public ❑ Other M Delta Depth of Grout Seal �l� �C+a- I I Irrigation lq,� Type of Grou. � 7 R] rL�Approx. Depth I I Eastern Surface Soul Installed by Repair Work Cone U Type of Pump H p - - Stats Work Cane _ WaR Destructiop D Well Diameter Sealing Material Depth X /YlOhl �✓t Depth Aller Material f Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOtTION I I DESTRUCTION 1 1 IN0 septic system permitted if public sower is Installation will serve: Residence_ Corretlrclal_ Other available within 200 fest.) , eh Number of living units: ,_� Number of b odrocros V Chuactu of aotl to a depth of 3 feet: y SEPTIC 7ANK. O Type/Mfg Water labia depth PKG. TREATMENT PLT.O Capacity No. Compartments �ry Method of Disposal Distance to^°°rest well Foundation Property line ! I LEACHING LINE O No. 6 Length of fns j FILTER BEDTotal leng[h/size I O Distance to rlwrast, Well Foundation Property Lina 1 SEEPAGE PITS II Depth �j Ste° SUMPS Number LI Distance[o rwrst Wall Foundation DISPOSAL PONDS ❑ Property Lira I hereby certify, telt 1 hove prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taw°, end runts and rsgulatiom of-tel San Joaquin County . Home owner or licensed agent's iignature certifm the following: "I certify, that in the perfarmance of the work for.Mich thio permit is towed, I shall and °^IPbY any Dusan In such manner s to becarrls arbtect to workman's compensation laws of California." Contractors hiring or wb•oontraohot certifies the foliowing: "I certify that in tel pertomwrlce of the work for which this permit is issued, I shall em to nng mpenura S- The laws of California." D Y persons sublect to workmen i r Alma is TM applicant ^lust or at r,egyired i trona Co sive-drawing on reverse sl Signed rifle: �Z2Z3 Date: I rt FOR DEPARTMENT USE ONLY �q Application Accepted by ---i7�='li_ -7 jytt .q� c. Date lY [ Area Ph a Grout Inspection DY n-°— C-11Date B 5 / - r Final Inspection by Den$ f `f Additional Commen4: Applicant - Return all copies to: San Joaquin County Public Health Services Eevironmrital Health Permit/Services S 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE A CK INFO /`7 dMOVNT REMITTED CASH RECEIVED BYj7 - �3 ATE PERMIT NO. . EN 11.24 G, �- FN ILJs �`7 l 73�{ h't. ';