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APPLICATION FOR PERMIT � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RECEIVED 445 N SAN J'OAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 S E P 2 2 1992 PERMIT EXPIRES 1 YEAR FROM DATE I SSUEJENVI RON MENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application In hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This 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 Services. APN40-2ff-0-V -0 Job Addr4w awae fW- &PwAt"-_!1-' `T�iK�/-BAc _-____ __ City-7 Lot Size/Acreage T'.O- fes[ �33�7 -�-ltl�f�f� �raw��_4�l�.92�'7 Owner's Name Address ,.___ Phone Contractor ddress 3062 S. icense NoLU2 Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPOLACEMENT 171 DESTRUCTION Z40ut of Service Well 0 PUMP INSTA_.LATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ ,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION TAGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications I'] Public C7 Other fl Delta Depth of Grout Seal Type of Grout I 1 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction EL Well Diameter ,r sealing Material 4 Depth 1 B�Lf�IT' Dep tiller Material i Depth _(/ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADOITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Other `ts Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth O SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to newest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application end 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-contraefing signature certifies the following: "I enify 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 appy t us all or ail r od i spgctions. Complete drawing on r roe side. SignedX. Title pate: 4z FOR DEPARTMENT USE ONLY ` Application Accepted by Data CzAArea Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, d Box 2009, Stkn, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED yj K RECEIVED BY OATE QP�EERM17'NO. . EM 13.26 U1EV.iir5! 6O .0 U �� [(f� Q /-3 & G 3 4Z [G A