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APPLICATION FOR PERMI f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE Ij ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 I+ P O BOX 2009, STOCKTON, CA 95201 AUG 1 1995 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) -ENVIRONMENTAL HEALTH PERM ITISERVICES Application is hereby Bede to Ben Joaquin County for n permit to construct and/or install the work herein described. This application is made 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. � , _V- np- CitycL It Size/Acreege ^f�Job Address 2, L . c,- Owner's Name' � rC n � Address �� 0hone(ni 2311 11 .4 .5Q R,S n cn, A• _q 7�- Contracts \l l r(7 '� Address License No. Piton '1 tt� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATIO��..Nyy r0.( SYSTEM REPAIR ❑ OTHER>(, Mon b2t Mng Well C3DISTANCE TO!NEAREST: SEPTIC TANK t�]..l".;— SEWER LINES DISPOSAL FLD WELLM� PR L1f'NE �Q- f FOUNDATION ( AGRICULTURE OTHER WELL L�.Fs.L_ PITS/SUPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA IONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio 1 77 Dia. of Well Casing n Domestic/Private 0�q Gravel Peck _❑ Tracy Type of Casing Specifications 1'1 Public - OthorDelu Depth of Gross[ Seal Type of Grou Itl I I Irrigation ij Lqf Approx. Depth/V d�Eastern Seal Installed byey Repair Work Done L3 Type Type of Pump -�-7`(-v r— H.P. �e � 14 Well Destruction ❑ Well Diameter ry1 Sealing Material i Depth ta[s Work Done ije nn!� Depth 'Y Tiller Material a Depth , TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is ij available within 200 feet.) Installation will serve: Residence_ Commercial _ Other Number of living units: _ Number of bedreoms Character of 10 ion to a depth of 3 feac Water table depth SEPTIC TANK.i ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ii Distance to nearest: Well Foundation Property Lina it LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED �I ❑ Distance to nearest: Wall Foundation Property Lints SEEPAGE PITS; It Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lows, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become wbject to workmen's compensation lows of California." Contractor's hiring or subcontracting signature cartilies 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 lows of California." The a an ust call for MR roquirr�ald paacti�ocn�s,. Cort\�p�to drawing on reverse side. SignWI�A 1 n .i - .i/l I till "[7f Title: Data: Er l . 401 rrl FOR DEPARTMENT USE ONLY Application Accepted by t` Date �" Area Pk or Grout Inepiction by pF I Oats .-1� Final Inspection by Dan Additional Comments: Applicant`- Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED I �AS11 RECEIVED BY DATE PERMIT'NO. [__ . EH,1]I(REV.I I x ml EH u.as ��^ V