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{ APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES D 4T ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 MAY 14: 1993 k.PERMIT MIRES_ 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is hereby made to SanJoaquin County for a Permit to construct and/or install the work herein described. This i_ 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 Servil ; Services. j� Job Address _ I W_ City r' Lot Size/Acreage Owner's NameA1-5 ass 112� Phone Z- 5(059 Contractor 11tlT�f t� Address &-a_La1._A/y41i� LAf *A- License No. S Phone 95;&-42-44 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �`�yfMo" "�Well ❑ DISTANCE TO NEAREST: SEPTIC TANK IJ 4 SEWER LINES DISPOSAL FLD. 012!1: PROP. LINE W_ rr I` FOUNDATION 'l5 AGRICULTURE WELL !` A OTHER WELL `?JA PITS/SUMPS !�L4 I' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing /F ,Rrborneslic/Private ❑ Gravel Pack Ll Tracy Type of Casing_ N�O Specifications Il Public Ci Other n Delta Depth of Grout Seal _32C? Type of Gout P f:J� I 1 Irrigation —.Approx.10opth VrEastern Surface Soul Installed - onLTZ,5v S cy_r 7- Repair Repair Work Done 0 Type of Pump O�A H.P. State Work Done _ Well Destruction ❑ Well Diameter i I'J )t Sealing Material A Depth p Depth 3e r - Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION f I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other f Number of living units: Nurn of bedrooms v Character of soli to a depth of 3 feet: + Water table depth SEPTIC TANK 0 Type/Mfg __ Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance tolnearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED I;7 Distance to nearest Well Foundation Property Line SEEPAGE PITS I I Depth 1 Size Number SUMPS LI Distance tonearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 iignatu►e,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 fogowing: "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 applicantpu3t call or all required in ctions. Complete drawing on reverse side. Signed Title: P /E�lr ��G�s7 Date: !! 7_ -� 3 +`i •` _{{-- FOR DEPARTMENT USE ONLY Application Accepted by " � �4Data - 2 3 Area '3 Z Pit or Grout inspection by Dole q�z _ Final Inspection by_ 64? ._, Date 9 Z Additional Comments: g`� Co 9&-r Applicant —Return all copies,-to: San Joaquin County Public Health Services } Environmental Health Permit/Services 11 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE ^" INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. t� r..� i • EN1121{AEV.iiNsls f7. t7C� f f_. f ;,IL4] f�t`q-OZ��7J Y�j^OI I� EH 14.28