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APPLICATION FOR PERMIT ypsjyx SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 AUG 19 1993 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/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 cowliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health jSe//rvices. Job Address �Y / W., llCe- jc A"6, &r.e _ City 4 Lot Size/Acreage -- t/4 act_ Owner's Name W ra~'ae + ht Address 5_4Z 5' PJ 7%--- 0 17c"� a CA Phone(,4 S. Y-OZ41 . 24, -- Contractor r"/rotor 4&4--Ir /4C. Address #644de Gowtowa 4 JrL1426 License No.C6 Z2?.a Phon K .'.` TYPE OF WELL/PUMP; NEW WELL J1 WELL REPLACEMENT 171 DESTRUCTION Cl Out of Service ke11 0 PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK �S'n SEWER LINES iSa 0 DISPOSAL FLD.-,ro 4 PROP. LINE 46-014 FOUNDATION Le_-f_a t4- AGRICULTURE WELL �f4 OTHER WELLse"!°s PITS/SUMPS ;t�19 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /O tN Dia. of Well Casing 4 to C) Domestic/Private 4 Gravel Pack ❑ Tracy Type of CasingSpecifications I'i Public 1"1 Other n Delta Depth of Grout Seal 46 Type of Grouter Cc`µ d Irrigation `S3Y'Approx. Depth I 1 Eastern Surface Seal Instailed Repair Work Done U Type of Pump H.P. State Work Done Wed Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 loot.) Installation will serve: Residence T Commercial— Other Number of living units: Number of bedrooms Character of sag to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that f 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 iignature certifies the following: "I 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 workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, f shall employ persons subject to workman's compensa- tion laws of California." The applicant must Call for 00 required inspections. Complete drawing on reverts side. signed „ AJ J�*`//L_-epp r�.'+.t14✓ Title: �+ e' . Date: !Y lJA ell woraft^t.A/ �Rr'rr� ti l 4t FOR DEPARTMENT USE ONLY Accepted by ... ._,_ Date � Area Pit or Grout Inspection by Date Final Inspection by I Date Additional Comments: Applicant - Return all copies to: San Joaquin County Puis Health Services Environment"I Health ermit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED Li_ L9k CREECCEIVED BY DATE 7QPEERM17'NO..`_1" IAEV.1 i n 5! g �� 1111/- Z Jam'rfJ 1,, -173&