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UAPPU I CATI ON FOR PERIL I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMTAL HEALTH DIVISIbN PAYMENT 445 N SAN JOAQUIN, PHONE (269)468-3420 RECEIVED P 0 BOX 2009, STOCKTON, CA 95201 { l F F 8 0 f 1993 PERMIT EXPIRES YEAR FROM D T S SAN JOAQU„N CO' .'tTY (Complete in Triplicjate) 1 PUBLIC HEALTH SERVICES � ENVIRONMENTAL JEALTtWVISE� Application is hereby msde.to San Joaquin County for a permit to construct and/or install the vork herein escr s 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. Job Address City 7TtJ[ d Lot Size/Acreage Owner's Name Rf.�1 �0�►flliLS17N9HAddrass O;�,. i1 I Phone 'l I ryT� . 1�10 VI,S- }� F--7 r,�r t i Contractor w � Address 1) 0 Bn?& 3� 9%:4 11 License No.5�lrlfr____�=1Phone TYPE OF WELL/PUMP: NE WELL V WELL REPLACEMENTC]� DESTRUCTION ❑ Out of service well ❑ .{� PUMP INSTALLATION El SYSTEM REPAIR C7 Monitoring Well OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK NI4- SEWER.LINES DISPOSAL OTHER PROP. LINE � f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 Q Dia. of Well Casing r� j 17.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— ThiC 1)i Specifications ,,��'',�� APublic 1-1 Other Delta Depth of Grout Seal l� ��I,I Type of Grout—sect _t I i Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by S Repair Work Done U Type o1 Pump H.P. I State Work Done Well Destruction ❑ Well Diameter sealing Material i Depth 1 } Depth Filler Naterial i Depth I1 � rr TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is i a;{`ailable within 200 feet.) + Installation will some: Residence— Commercial_ Other Number of living units: Number of bedrooms �!' Character of soil to a depth of 3 feet. IP Water table depth 1 SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKC. TREATMENT PLT. ❑ i' Method of Disposal Distance to nearest: Well Foundation I Property Line LEACHING LINE Cl No. & Length of lines Total lengthlsisa y FILTER BED ❑ Distance to nearest. Well Foundation ' P M party Line SEEPAGE PITS I I Depth Sire Numberl� SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I i� 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 I - Home owner or licensed agent's signature certifies the following: "I comity that in the performance of the work for which this permit is issued. I shelf not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature f certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion tars of California." ` The applicant mu call for all requited inspections. Complete drawing on reverse side. !I Signed Title: Pais ai _ Date: ��y ° FQB DEPARTMENT USE ONLY II r Application Accepted by Date IT' l ' ! Area Pit or Grout Inspection byDateDate final Inspection1by A s@etp Additional Comments: V b31 k Applicant - Return all copies to: San Joaquin County Public Health services j Environmental Health Permit/Services iI �t 445 N San Joaquin, P U Box 2009, Stkn, CA 95201K# 11 r 111 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By OATE PERMIT'NO. • EEN T3-24 N t1.2e Ill I/pis) 1 X3426,2 � I