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APPLICATION SAN AQUIN COUNTY PUBLIC HEALTH :RVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 z, P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sm Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 5L9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I _ ,f � / 11 �� ! y Job Address hek1/Cu✓/!c✓of / � ° ''�' �`'y� �S✓ OlJ-So)CtY �, !' Lot Size/Acreage Owner's Name �0 Z Z !��"�/� - /��/Address "6/ ��c�i�l•�G'�i� l�, T�t ' vvLE Phone /�/ Contractor 19" 1L y 1111n4 C' Address L/`9 toljmlei� IV 4alkljllh elLtcense No.3oG2-T-C67 phone(9l. S Gla TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT i DESTRUCTION C Out of Service Well Cl PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER C Monitoring Well- DISTANCE ellDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES > 70 rrDISPOSAL FLO. , ^� PROP. LINE; SO��'1 FOUNDATION ::]�L AGRICULTURE WELL jt-L4—jt-L4—� OTHER WELL 300 PITS/SUMPS ZV- 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation I d Dia. of Well Casing Q Domestic/Private Gravel Pack gTracy Type of Casing_ Specifications I'! Public 1-1 Other fl Delta Depth of Grout Seal 3O Type of Grout I ! Irrigation Approx. Depth I I Eastern Surface Seal Installed by �i✓1�lPi✓ YI f DYII�.1 �' Repair Work Done L Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material 4 Depth (� Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION 1 I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments .� PKG. TREATMENT PLT. ❑ Method of Disposal„ - �( Distance to nearest: Well Foundation Property�i T.°1•� �_' r LEACHING LINE D No. b Length of lines Total length/siz " `^" -t FILTER BED O Distance to nearest: Well Foundation Property oro Qi v SEEPAGE PITS 11 Depth Size Number SUMPS L) Distance to nearest: Well Foundation Protii.i Line DISPOSAL PONDS Q' 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 certifies the following: "I certify that in the perlormance of the work for which this perrrut is Issued, I shall not employ any person i uch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies th g,/,I c 'fy t in t7spections. rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa ' tion law _of Ii/r j The a li al r req r d Complete drawing on reverse side. Signe Title; Project Manager Date: July 1, 1992 Mark S. D 6ICuyl CE.G• FOR DEPARTMENT USE ONLY Application Accepted by Date Area r Pit or Grout Inspection by / /�/ Date Z Final Inspection by Date �g Z ®Additional Comments: ` 4 ' ' V�M- 01-4' �7- 10 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P C Box 2009, Stkn, CA 95201CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE I PERMIT NO INFO + EH 13-24 IREV iI.�i V !i ' (/[J ✓��/ 4 I / !� �/�� EH 14-2e i' '