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.5 APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 OGT 2 4 1994 P O BOX 388, STOCKTON,CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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 Development Title Section 9-11110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. O 700 �D DT ��yS'hr �"�- City 5�`��/u"' Lot Size/Acreage �^� ' Job Address n � -- Owner's Name CAL;i l NS Address f30X Z D�g _ Phone 1 l M 7PhoneS2 -2 9 r� YYl�t r� G O• Ir d V Addr � License No. Contractor a eS5 - r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well 0 PUMP INSTALLATION G SYSTEM REPAIR G OTHER �{ Me storing Well P f'IaZ Gv+c��elr DISTANCE TO NEAREST: SEPTIC TANK y SEWER LINES `� DISPOSAL FLD. r PROP. LINE 16rf- FOUNDATION �� _ AGRICULTURE WELL �� OTHER WELL—'— I' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom 0 Manteca Die. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack n Tracy Type of Casing_ Specifications I'I Public 16 Other i-1 Delta Depth of Grout Seat Type of Grout I I I Irrigation �Approx. Depth -KEastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material. A Depth Depth _ Filler Material i Depth �►� i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRrAODITION I > DESTRUCTION I I (No septic system permitted it public "war is available within 200 feet.) Installation will serve: Residence_ Commercial T Other r Number of living units: Number of bedrooms Charactef of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Gl Distance to neatest: Well Founoation Property Line " SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation . Property Line DISPOSAL PONDS O I hereby canify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin County ,: Home owner or licensed agent's signature certifies the following: "I certify that in the peilormance of the work for which this permit is issued, I shall no � employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of subcontracting signature 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 compen" tion laws of California." i The applicant. st ca for all K 97tred inspections. Complete drawing on reverse side. _ t Signed '�'��"�-� Title: . 5ra�'I/ _. Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 'r I"' • Area y� Pit or Grout Inspection by Date Final Inspection by _ Mte ` Z, l Additional Comments: S Applicant - Return all copies to: San Joaquin Cou y Public Health Services Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388FEE Y e^ INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED 6Y DATE PERMIT'NO. rn r EH 17-211REV.vNSi EH 11.2afff!!!/// t