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APPLICATION } !S SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209}468— gJV P O BOX 2009, STOCKTON, CA 9520 PERMIT EXPIRES."1 YEAR FROM DATE ISSU V 1 2 1993 (Complete in Triplicate) �� Application is hereby made,to San Joaquin County for a persalt to construct and/or lnsta3ry�S�h ' Rt I abed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and t tions of San Joaquin County Public Health Services. I rr Job Address =t;!I�-AWAO City Zao/ Lot Size/Acreage / Owner's Name Address�Tl. /�' p�U� '^r�v� Phone Z/V2 z O/ -P.0 Contracto AddressjW3 1:&J 4V License Ne. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (-1 DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ ` SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well A+f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE: OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom © Manteca ;, Dia, of Well Excavation P7 pia. of Well Casing Z" Cl Domestic/PrivateGravel Pack ❑ Tracy Type of Casing�LTG SG1f V ; Specifications I"I Public la Other Delta i Depth of Grout Seal Type of Grou I I irrigation Approx. Depth 1 I Eastern Surface Semi installed by _ W�Ak- 42� 4-0+_ Repair Work Done U Type of Pump H.P. tate Work D e Well Destruction ❑ Well Diameter 7/1 Sealing Material i Depth BtTMIce Depth ss'_ Filler'Material i Depth #3 S¢a✓&2 _ ... TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION 111No septic system permitted it,public sewer is available within 200 feet.) Installation will serve. Residence-___, Commercial— Other Number of living units: Number of bedrooms !I Character of soil to a depth of 3 feet: Ii Water table depth SEPTIC TAMC. ❑ Type/Mfg it Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 8 Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well ?I Foundation Property Line I SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI r� I 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 reguletions of the San Joaquin County Ig 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring of sub-contracting 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 compensa- tion laws of California." € The applicant all r req ired in tions. Complete drawing on reverse side. Signed Title:! ��/6Zi- .�t'�--- Date: �� _ • FOR DEPARTMENT USE ONLY / ri Application Accepted by ' �` Date Lq3 Area Pit or Grout inspection by Date Finai Inspection by Date 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 1NFOK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO, r4 I