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r� APPLICATION FOR PERMIT }� _ SAN `, AQUIN COUNTY PUBLIC HEALTH 1SIRVICES ENVIRONMENTAL HEALTH DIVISION I `�I 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 MAY 14 11993 PERMIT EXPIRES 1 YEAR FROM DATE ISSUID ALTH (Complete in Triplicate) ENVIRONMENTAL PERMITHEERMIT/SERVICESS 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 Health Services. Job Address1=1 City 5!�-t"r�'� Lot Size/Acreage Owner's Name 5Mc&&I A,1 (,�rW-0 )15-5 ss 1ZZ- Ill (nJt L V 1"II &I Phone Z- 5&551 Contractor "T_ Address 623 W- AA4*4-14'LAJ * License No.50- 44 7!1 -Phone q5;&G TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER �1:��4°II�ti�2i 11 O DISTANCE TO NEAREST: SEPTIC TANK 0 14 SEWER LINES 1042' DISPOSAL FLO. OA- PROP. LINE 1=2 FOUNDATION L! AGRICULTURE WELL ±:L/—A OTHER WELL±!/L— PITS/SUMPS �4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation `� Dia. of Well Casing IV '4' ,WDomestic/Private O Gravel Pack ❑ Tracy Type of Casing 0/4 Specifications 1'1 Public n Other n Delta Depth of Grout Seal Type of Grout QaaL"JD I I Irrigation _Approx. Depth ' - XEastern Surface Seal Installed by . QW+'T'Z�rpJ a MT CSETf Repair Work Done U Type of Pump y,LAw H.P. State Work Done_ Well Destruction O Well Diameter N A' Sealing Material i Depth Depth 30 r Tiller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION 11 (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,O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. A Length of lines Total length/size FILTER BED O Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin County 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, 1 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 t caU or aN required in tans. Complete drawing on reverse side. Signed /PZA972� Title: P/�ct/ELT��GtS7— Date: 3 -9 3 FOR DEPARTMENT USE ONLY UJ Application Accepted by ` Data 06-22-- l5 /6"-2 2` l 5 Area 1-67- 4dPit or Grout Inspection by Date Final Inspection by o-Q k Date 2. q Additional Comments: ev G (,/.? G� 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 8 RECEIVED BY DATE PERmirw. . EH 13.24IeEV,I/8sl $� g� •�� CjC( . oo ro`! .,—t,J ofu-oZ-�13 `13-o`�`T8 EH 14-M