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APPLICATION SAN JOAQUIN COUNTY' PUBLi HEALTH SERVICES i ENVIRONMENTAL HEAL DIVISION PAYMENT 445 N SAN JOAQUIN, PHOIE (209)468-3420 P O BOX 2009, STOCg ON, CA 95201 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J U N 17 1993 (Complete in Triplicate) SAN JOAQUIN' C01UNFY PUBLIC HEALTH SERVICES Applieatiod is hereby made to San Joaquin County for .a permit to construct and/or lastalEEp]�id�Lias� tis 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... .lob Address _ 0� L's 1L15P1'vll Ci,y nJ*Q__ Lot Size/Acreage � c c z j `4V f1 NC � �7 � i Owner's NamePhone + g 1- ! P- v Contractor D t��; 11E Address36[r: .mea- (iYci triseNo. 5 111 12 Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT M DESTRUCTION ❑ Out of Service well -❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER altos ng )Tell ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE beTl h�a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia.of Well Casing f] Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casi g C fie- - --- Specifications 11 Public Other fl Delta ,. Depth of Gra it Seal Type of Grout 6141 I I trrigation —Approx. Depth I 1 Eastern Surface Seal nstalled by Repair Work Done 0 Type of Pump H.P. State Work Done Depth i D i t M Scaling Material ep Well Destruction ❑ well Diameter Sear { Depth Filler Material Z Depth TYPE OF SEPTIC WORK; NEW INSTALLATION i 1 REPAIR/ADDITION i i DESTRUCTION I 1 INo septic system permitted it public sewer is i 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 i SEPTIC TANK ❑ Type/Mfg Capa ity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundatio Property Line SEEPAGE PITS -- 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundatiott Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the worts 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: '9 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 workmen's compansatior laws of California." Contractors hiring or subcontracting signature certifies the following: "I cartify that in the performance of the work for which this permit is issued, l shall employ persona subject to workman's compensa- tion laws of California." The applicant must cZfoI uired ins ctions. Complete drawing on reverse si e. rSigned X � a Title: —ec- i s Date: FOR DEPARTMENT USE ONLY S� Application Accepted by Date Area Pit or Grout Inspection by Date `'23. 3 Final napection by Data 6'Z- Zf 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 95201FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO.