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APPLICATION FOR PERMIT # SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E NV I RONJIE NTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 w � P O BOX 2009, STOCKTON, CA 95201 PERMIT EXP I RES 1 YEAR FRQM DATE ISSUED ' ;7cv ► (Complete in Triplicate) 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 ccwq liance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 7 `�� i J r Job Address 'W,- "- f _ - -- City �I dlLLot Size/Acreage Owner's Name- �=�lLIP, ICWi T Address es / It ' Phone ' 7_32,49 Contractor M ( 13H r llt•it. Address [LUVISeVLS /*e CJPrC''fi __ License No." 6_2�_ Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT .. DESTRUCTION Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 0 Monitoring Well C] DISTANCE TO NEAREST: SEPTIC TANK 17 aG SEWER LINESt v7�f DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.-of Well Excavauan �GZ� Dia. of Well Casing t5y4omestic/Private tgiravel Pack ❑ Tracy Type of Casing_ � Specifications I'] Public 1-1 Other 11 Delta Depth of Grout Seat Irrigation of Grou II i I I Irrylatio �cpproK. Depth [ I Eastern Surface Soul Installed by �/ [C Ax tl,J .r Repair Work Done Q Type of PUMP. H.P. State Work Done T Well Destruction b4- Well Diamet * 8mling HaterM a Mtn { Depth mzzj,I rI hiller Material i Depth �°►F' y �gS/J'� 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 feet.) Installation will serve: Residence___ Commercial= Other (� Number of living units: Number of bedrooms Character of sols to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line Zi LEACHING LINE 0 No, 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line e II > SEEPAGE PITS 11 Depth t Siva Number l SUMPS LI .Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I�+ rI 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 Sen Joaquin county i 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 t 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for aB required inspections. Complete drawing on reverse side. Title: L-5111 Le _ Date: (6--/x-93 : �Ofl DEPARTMENT USE ONLY �A f Application Accepted by If Date _fest Areas Pit or Grout nspselion�by Date Final Inspection by Additional Comments: la- 7 b - Applicant - Return all copies to: Sea Joaquin County public Health S rvices � Environmental Health Permit/Services 445 H San Joaquin Box 2009, Stkn, CA 95201 43 ,70 ffFEaAiV,7DtIE AMOUNT REMITTED CK EIVED BY ATE ERMI-I-N . Em0-ri111Ev,rrsalr:f! / ] EN Nr Q # " iIdV �1.V