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APPLICATION FOR PERMIT 00 2�go SAN JOAQUIN COUNTY PUBLIC HEALTH S V qummwnttttwwolrs' ENVIRONMENTAL HEALTH DIVISION Aft 445 N SAN JOAQUIN, PHONE (209)468 AMT P O BOX 2009, STOCKTON, CA 952 ICA PERMIT EXPIRES 1 YEAR FROM DATE ISSUIM (Complete in Triplicate) r 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. 2 (wlr av 6�✓�. n 61 Lot Size/Acre e etre Job Address �+ City g8 i4,o. Box �oT2 Owner's Name �Xk'H �� ' Address C401u+ll Cfi 5fSZ4F - ZolZ Phone / Contractor i- Address �i.. �. t-+^�•✓e CA fifii Z License No. ilOZ A 7--' Phon&V&S2 - X40 TYPE OF WELL/PUMP. NEW WELL 54- WELL REPLACEMENT 7 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES � is, DISPOSAL FLO. � r PROP. LINE -1 r FOUNDATION Sar AGRICULTURE WELL tr__S OTHER WELL 7 T UMPS y , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial Z rr O Open Bottom ❑ Manteca Dia. of Well Excavation ta. of Well Casing Q /)VC S`4 4� [] Domestic/ Private ❑ Gravel Pack [I Tracy Type of Casing_._ Specifications � I'l Public �r 1 (*Other t-1 Delta Depth of Grout Seal y Type of Grout#0e•/ Ce -C'.14 I I Irrigation Z:� Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth L1 Depth Filler Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION 1 1 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: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments N PKG. TREATMENT PLT. ❑ AMOUNT DUE AMOUNT REMITTED Method of Disposal RECEIVED BY Q PERMIT' N0. 4C Distance to nearest: Well Foundation Property Line r�� 1 U'E D LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED 1-1 Distance to nearest: Well Foundation Property Line MAR 15 1994 6NVT1RQNMETAL HEALTH SEEPAGE PITS I I Depth Size Number A QAAR, 1 5 SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 workman's compensation laws of California.'' Contractor's hiri ting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall empty a subject to workman's pensa- tion laws of CNifornia."� n C) � � rb The applicant must call for all required inspections. Complete drawing on reverse side. 1, C i Signed X r `'�• "e o•t-G��(� Title: �`1�fe�rc•%s rIT Date: Application Accepted by Pit or Grout Inspection by Additional Comments: Applicant - Return all copies to EH 13-21 (REV. 1 n s, EH 14-2a San Joaquin County Public Health Seraces Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY PERMIT' N0. 4C cz V [ /� /DATE 10025Pkn