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APPL I CAT ION jpg ZAN JOAQUIN COUNTY PUBLIC HEAL71 44, ENV I RONMEN TAL HEALTH DI V] 445 N SAN JOAQUIN , PHONE ( 209 ) MAY 1 9 1994 P 0 BOX 2009, STOCKTON , CA ' 20/1 PERMIT EXPIRES 1 YEAR FROM DA ENVIRONMENTAL HEALTH (Complete in Triplicat PERMIT/SERVICES TPA& Application is hereby made to San Joaquin County for a permit to construct an Th-TTEle1715Ett.----Thi application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations o a Joaquin County Public Health Services. U07 tv $ TO CAT'014 Lot Size/Acreage 2 C-- Juu,u,.... Owner's Name 6V-45 GCIt4T /C. onfforT- A; r Address P.o. BON 11 5' kl, sToc4i1ovt 15-241 Phone 466'14 6 0 1 ...IPP.riljoi9 Contractor 64010,1iCal Aitelilth40 041.1‘4€1 Addren 4 ID I g 0 3 vo• Plarok 1. Pi stAsilLicense No. 5' VI 631 Phone ¶5. 6 - 0 26 1-1 TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT 0 DESTRUCTION El Out of Service Well 0 )4 PUMP INSTALLATION 0 SYSTEM REPAIR il OTHER 0 Monitoring Well / DISTANCE TO NEAREST: SEPTIC TANK tis fft SEWER LINES (O f DISPOSAL FLD. WM PROP. LINE 5 I FOUNDATION 75 AGRICULTURE WELL /1/h OTHER WELL I " PITS/SUMPS w/A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ni / 0 0 Open Bottom LI Manteca Dia. of Well Excavation 43 Dia. of Well Casing A Industrial 0 Gravel Pack Li Tracy Type of Casing r V C., Specifications )4, Domestic/Private f 1'1 Public n Other Ii Delta Depth of Grout Seal 30 Type of Grout P0 /414 n 4 e•*1414: Approx. Depth )Eastern Surface Seal Installed by Pikik Gray V 0 I tli at, N er 1 I Irrigation _ Repair Work Done 0 Type of Pump H.P. State Work Done • 0 Sealing Material & Depth Well Diameter Well Destruction Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION i i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence Commercial Other i 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. 0 Method of Disposal Distance to nearest: Well Foundation Property Line \ LEACHING LINE CI No. & Length of lines Total length/size .... I FILTER BED El Distance to nearest: Well Foundation Properly Line I SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 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, I shall employ persons subject to workman's compensa- tion laws of Calif la." The applicant Signed X ired ins omplete drawing on reverse side. Title: Date: 5-7-1,- 7/1 DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: Date 21/2-4P 1 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED CK SI CASH RECEIVED BY DATE ' e NV f 72.-. 77 p el Li' /Z t1-16,1 cf. s-A-17v. ao-3/2 1,6't EH 13-24 IREV. 1, 5) EH 14-213