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_ APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE S (Complete in Triplicate) Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in ccoa liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Bervicee. �� ,_ � Cit Lot Size/Acreage -Z49 /7C Job Address � iy� �(•.�{ �].�-�G ` ,. Owner's Name ►'l \ ] LZ.�L1 Address �r> �"' S a �/�'�- Phone '�<!- Contfacto d-. is ti I t Address I a/ pefe r License N Phone' - TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT n DESTRUCTION Ll Out or Service well Cl PUMP INSTALLAT ON ❑ SYSTEM REPAIR ❑ OTHER 0Monitoring Veil ❑ DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES - - DISPOSAL FLD. PROP. LINE 2503 --"`—FOUNOATION L3��- AGRICUL-TURE'WEL�-OTHER WEL�L°1i�1TS/SUMPS— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia.of Well Excavation_G� Dia. of Well Casing �! domestic/private gavel Pack* ❑ Tracy Type of Casing__.._._ - Specifications I1 Public EI Other Fl Delta Depth of Grout Seat VIP.ofRGrout I I Irrigation �i� l pprox. Depth I I Eastern Surface Saul Installed by II Repair Work Done a L3 Type of Pump H.P. r State Work Done - r Sealing Material i Depth Well Destruction ❑ Well Diameter Depth Filler Material i Depth = TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 foot.l !+ f Installation will terve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Typo/Mfg Capacity No. Compartments I PKG. TREATMENT PLT.0 ' i Method of DOMMENT Distance to nearest: Well Foundation Property LineRECAVE® LEACHING LINE ❑ No. & Length of lines Total length/size FIAR 17 1993 FILTER BED 0 Distance to nearest. Well Foundation Property Lino 1 AQI,�IN AUNTY USLIC HEALTH 80VICES SEEPAGE PITS 11 Depth Size Number ENVIRONMENTAL .R--.. - w..r -- Y _ to oprtSUMPS Limseneal oundation DISPOSAL PONDS ❑ i 1 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: '9 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 comity 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." r The applicant rrtbst tali for all raquir ins tions. Complete drawing on re arse side. / c Signed X / f. v - - - Tice: .-t4 ✓i ®ate - 3 a FOR DEPARTMENT USE ONLY kApplication Accepted by110�4Data Area �� Pit or riiut nspaction by ! DateFinal nspec on by Date Additional Comments: Applicant - Return all cops s tlo: San Joaqu� ty Public Health Services ` Environmental Health Permit/Services i 445 N San Joaquin, Box 2009, Stkn, CA 95201 FE AMOUNT DUE AMOUNT VEMITTED CAS RECEIVED SY DATE PERMIT'NO. j F . fm 1$,24InEV.r/RS) // %� � n Eli t01-a YJ