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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESE VE D ENVIEONMENTAL HEALTH DIVISION RECvml% :445 N SAN JOAQUIN, PHONE (209)468-3420 MAY 18 1993 P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH PERMIT EXPIRES I YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) Application is hereby made to Sem Joaquin County for a permit to construct and/or install the work herein described. This application is made 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health rvices. Job Address • 33 04&tiLvxCity Lot Size/Acreage Owner's Name YQf�f�� Address Phone Cantract Addre �License — Phon TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT .l.l DESTRUCTION ❑ Out of Service Well ❑ + _ / Monitoring Well PUMP INSTALLATION ❑ � ,� SYSTEM REPAIR/ OTHER ❑ � [7 DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES y.. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r D ' INTENDED USE TYPE OF WELL�=' PROBLEM AREA CONSTRUCTION SPECIFICATIONS (�J indystriai ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing � omestic/Private ❑ Gravel Pack n Tracy Type of Casing_ Specifications I'1 Public f-7 Other- , . - ..L�, n Delta Depth of Grout Seal Type of Grout I I Irrigation 11" —Approxi Depth i I Eastern �ySurface Soul Installed by Repair Work Done CBI' Type of Pump H.P. — _ State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material & Depth P TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public saw' is available within 200 feet.) Installation wilt 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. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line .1 - LEACHING LINE „ ❑ No. &'Length`of-lines Total length/size FILTER BED ❑ Distance to:nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth-i 1 Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI r 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`regulatiobs of the San Joaquin-County— Home County Home owner or licensed agent's ii nature certifies the following: - - g 9 g: "I certify that in the performance of the work for which this'permil is issued, I shati 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 permitlelssued, l shall employ persona subject to workman's compensa- tion laws of California."' The applicant mu al! required ins ctions. Complete drawing on r rse side. Signed Title: Date: .. ' tREPARTMENT USE ONLY Application Accepted by Date a I 1�] -- Area_��:.�.�• Pit or Grout Inspection by Date Finaf`lnspection by kta Date -4-1-f-3 f Additional Comments: f `i 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 K0 RECEIVED BY DATE PERMIT'NO. ` • EH14.26INEV.1inSl 1*611 f Dv !t