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APPLICATION FOR PERMIT IT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 I; (209) 468-3447 PERMIT EXPIRES 1 YEAR rRom DATE ISSUED 15 1995 (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install tiiiiRtrArlIVAnso p, ,ibed. This ENVI RONMENTAt/i Hp,;4-6d application is made in compliance with San Joaquin County Ordinance No. 5 149 and 1862 and the Rules -a-rid Ftgulations of San Joaquin County Public Health Services. Acrea e Z 0)((- Job Address / --- U., ' .-..- e ,... . -,..j _ , _ _ ,,,,, Owner's Name —S' /9 /667:9S74 ") Address IP a Box 97,2a V,- or7 ,-63Jo Phone P5 P -----3 6 r cf / )--se0-20 -02/1 Contractor 74 6 c '‘ /A Addres s 173° /Parc', /CA vlOWL License No.( 7-32 Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT - DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 • • R 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I, Cl Industrial 0 Open Bottom rit Manteca Dia. of Well Excavation /0 '' Dia. of Well Casing 2 4 " 0 Domestic/Private Or-Gravel Pack 0 Tracy Type of Casing P V c_ Specifications Pk-C.- 0 Public Cl Other 0 Delta Depth of Grout Seal Type of Grout )1 e4,1 L 0,77.6A-7i CI Initiation _ Approx. Depth 0 Eastern Surf;ce Saul Installed by Repair Work Done 0 Type of Pump r M.P. State Work Done Well Destruction 0 Well Diameter 2-4 it Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1:3 REPAIR/ADDITION El DESTRUCTION D (No septic system permitted if public sewer is available within 203 feet.) Installation will serve: Residence mmercial Other Number of living units • Nu er of bedrooms Character of soil to a depth of eet: Water table depth SEPTIC TANK 0 ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT,Z1 Method of Disposal Distance to earest: Well Foundation Property Line LEACHING LINE 0 . & Length of lines" Total length/size FILTER BED Distance to rest: Well Foundation Property Line SEEPAGE PITS I I De Size Number SUMPS LI !stance to nearest: Well Foundation Property Line rusPOSAL PONDS rY ns. Complete drawing onre se side. ex Title: Date: f-Ar-fr FteOR DEPARTMENT USE ONLY Da Data 1C3 Area Date ‘l Final Inspection by Additional Comments: (T)c/trte- 5 A4z 23-2- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 ' FEE INFO AMOUNT DUE AMOUNT REMITTED CK i CASH RECEIVED BY DATE mil . NO. 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• lion laws of C • ornla." The 'police ust call f r requir Signed Application Accepted by Plt or Grout Inspection by Applicant - Return all copies to: $1 13.24 IREV. 1/A Si 14.2D /,b5 5 5-19/