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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 ` (209) 468 *342-0 C .' 2 1994 PERMIT EXPIRES I YEAR PROM DATE ISSUED (Complete in Triplicate) EMS'-<OWT-N'AL.HEALTH PE;&ff/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 Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public `H'e'alth Services. Job Address �S� (.c�,151 AJ,4 0-A.3 814V46 City s7o4e7o- J Lot Size/Acreage rye OwMr'e Name'1 0 SrpF CM T" CC. • Address Qt Uc/'S'i 1 e,CA Vd2 Z Phone Contractor +U) ' O Address r 0 1 fa_ License No.6S W 186 Phon� TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT O DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 4ZZA SEWER LINES 2 / DISPOSAL FLD._41_. PROP. LINE/� FOUNDATION 7S/ AGRICULTURE WELL,dy-A— OTHER WEL4&Zd PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private • • Gravel Pack O Tracy Type of Casing .'1 G- Specifications(SI 4 40 9 P,obtie .4Wj ,TV1Z- ((�'1ccO11ther XDelta Depth of Grout Seal SLIZEaCE _ Type of Grout02iL 6Ad— G Irrigation Z2 Approx. Depth ❑ Eastern Surface Saul Installed by 00w I;a n12- Repair Work Done U Type of Pump H.P. State Work Done _ Will Destruction O Well Diameter Sealing Material L Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/Ab01TION ❑ DESTRUCTION G INo 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. ❑ Type/Mfg Capacity__. No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE n No. 8 Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation _„_^ Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby cenify 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 cenify 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 workmen'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 u II all req ired in pections. Complete drawing on reverse side. / Signed Title: �yi_-y i4y'l- Date: 1d/1,6lf914-° FOR DEPARTMENT USE ONLY /) Application Accepted by r Data Area Pit or Grout Inspection by ate /L Final Inspection by 1 Date 'n, Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES / ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CCA�SSH RECEIVED By DATE PERMIT'NO. FH 1`.24111Ev.r I*$)