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lC, SR # #� SAN JOA( AID Er 445 14 FAC # P O INV # SSS PERMIT APPLICATION ]IN COUNTY PUBLIC HEALTH SE 1 I RONYENTAL HEALTH DIVISION AN JOAQUIN, PHONE (209)468- 420 t` BOX 2009, STOCKTON, CA 95201 NOV 1 01993 u �L&.ULJ 1 li . XL%W= LJt]1L' LugNMENTALHEALTH (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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. -1 A ---- / qDDID AQ -1. I 14Vr V Q r;.,, L0C-KEF0QD Ent. Size/Acre"e ICC X Ii5 ' APPOZX Owner's Name Time ply- CO"1104W y Address 2-131 N/, C.Ommt:D0Cr= W4Y I SE'ArTL�Phone AMOUNT DUE (,EO _E-NVrr2u"mi'ryTAL ContractorZEAC-ORDR0.11-IM6 Address C.0.9ote 3s9:9' ,Yu Ba Cir License No.CiI b 16y23Phone `30C 6i/ -Z42 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER( Monitoring Well ❑ V4PcC u:C-tL DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES !DO ' DISPOSAL FLO. PROP. LINE -2C-.::- sLFOUNDATION FOUNDATION12' AGRICULTURE WELL — OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7, S `' _ Dia. of Well Casing Z - IN64 F) Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing__ (VL Specifications SeN O I"1 Public EI Other n Delta Depth of Grout Seal 2C.' Type of Grout KEIT I I Irrigation Pe :Approx. Depth ID( Eastern Surface Seal Installed by Repair Work Done U Type of Pump H. P. ____ State Work Done — Well Destruction ❑ Well Diameter Sealing Material & Depth GErnFFfr - &C -N 1-041 T67 2-S tb 612 4 DG if S.61L ._.A► N1*46 Depth Filler Material & Depth *-' ,- fiND ZS" -y cD rl TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: 1 Number of bedrooms Character of &oil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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, I shall not employ any person in such manner as to become subject to workmen'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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant musk calL for all ftinspeclions. Complete drawing on reverse side. Signed X Title: 6'04 1ct2 C�EaLC��t' T Date: 1'' 1-9 23 R DEPARTMENT USE ONLY _ Date Area y Date Final Inspection by Date Application Accepted by Pit or Grout Inspection b 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 95201 • EM 13-24 (REV. v n 51 EH 14.20 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK If RECEIVED BY DATE i-