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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH S'TRVICES PA 1 ENVIRONMENTAL HEALTH DIVISION JZEGEJV El yT 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 AU ANQ et 0P,2 3 1993 PERMIT (Complete iaATrFpO�cate) ISS if�DiR IyFN A�y�HS EIV Application In hereby made to San Joaquin County for a permit to construct and/or install the work herein�decH4�$ 1s application is made in ccMliance with San Joaquin County Ordinance No. 549 and 1862 Lad the Rules and Regulations of'San Joaquin County Public Health Services. Job Address 17 0 0 c .TT I 1 G WWAq (ZgD _ City_OC I Pa t � Lot Size/Acreage G Owner's Name t +• Address N Phon� -r aoq Cantractot EG'n2r1 Z-OPAddressZ 1SrZQ-- License No. S12, Phone �- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E-1 DESTRUCTION/,,Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring wells DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F.LO. PROP. LINE H LC)i I t � 3 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , 17 Industrial ❑ Open Bottom ❑',Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestit:/Private ❑ Gravel Pack7 a Tracy Type of Casing Specifications I'1 Public C7 Other Cl Delta Oepth of Grout Seat Type of Grout - I I Irrigation —Approx. Depth I I Eastern Surface Saw Installed by Repair Work Done 0 Type of Pump H.P. State Work Qlano Well Destruction XWell Diameter Sealing Materia.' i Depth CGM 1a l KIWIIylI1J2 Aw-2>Depth to S� _ Filler Material i Depth SI LACE ��1.� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADOITION I I DESTRUCTION I I Wo septic ristern permitted if public sewer is available within 2W feet.) Installation ll serve: Residence— Commercial-__- Other b_ Number of Itvi units: Number of bedrooms Character of soil to depth of 3 feet: W bt epth SEPTIC TANK. Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance t arest: well oundation Property Line LEACHING LINE 0 No. b Length of li - Total length/size FILTER BED C3 Dig tance rest: Wei! Foundation Property Line SEEPAGE PITS Deplh Sia• Number SUMPS Irl rty Distance to nearest: well Foundation PropeUnit DISPO PONDS ❑ 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 regulations of the San Joaquin County Home owner or licensed agent's signature certirms the fallowing: "t certify that in the performance of the work tot which this porn-it is issued. I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or 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 compensa- tion laws of California." The applicant call for all requ' ns. a drawing on reverse side. / Signed Title: C ,77-(- ru z '3 Date: y f 4 3 C� FOR DEP RTMENT USE ONLY (� Application AeCaptad by Data Pit or Grout Inspection by Data r�''Final Inspection by '/ Data Additional Comments. A '�2 102 \A.)�i^ &ft Applicant - Return all copies to: Sap Joaquin-County Public Health Services. — .. Environmental Health Permit/services 443 N San Joaquin, P 0 Boa 7009, Stkn, CA 95201 CK 11 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATE PERMIT'NO. INFO A_ r e��/ . Ex 13-24inEV.riesr 1 }-- t24 ? o EH 14.7e VVV/ ,r