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APPLICATION XJ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES " ECER x" ENVIRONMENTAL HEALTH DIVISION K 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 J U N Z 6 1992 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENV IRQ{' MENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is hereby made to San Joaquin County for s permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules a=d Regulations of San Joaquin County Public Health Services. r Job Address-3 7 E M T' City L d Lot Size/Acreage ( Q Owner's Name616(I L; s b ECC -Address T 7 W� S� �' £�T Ld d lJ Phona 4D ` Contractor D2L'rl,� Py12F%Q_-^ AddressC 'C`a to License Na/k_uPhone ��6� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION Cl Out or Service Well ❑ PUMP INSTALLATION © I SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA! CONSTRUCTION SPECIFICATIONS i-} industrial O Open Bottom ❑y Manteca � Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack C7,Tracy Type of,,Casing} Specifications Il Public L.1 Other n!Delta i Depth of'Grou:;Seal e ' Type of Grout h f I-I"Irfigation __ .Approx. Depth. I Eastern $yrrf ce Seal Installed Iby �J Repair Work Done W Type of Pump a H.P. . rim °i' `Slate Work Done j on We p ll.Diameter Sealing Material 6�Aepth Well Destructi �..,_nte —_9__._......... .. 1, Depth ; �� fller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet,) Installation will serve: Residence Commercial— Other' Number of living units: Number of bedrooms ! Character of soil to a depth of 3 feet: s Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments j PKG. TREATMENT PLT. ❑ 11 � Method of Disposal 1 I Distance to nearest: ,Well !• Foundation Property Line �r LEACHING LINE Cl No. & Length of tines �� E � Total length/size FILTER BED ❑ Distance, to nearest: Well Foundation Property Line 1. SEEPAGE PITS II Depth ¢' J._.Sire Number SUMPS CI Distance to nearest: ` Well Foundation Property Line F DISPOSAL-PONDS—D— I ONDS'^'_Dr»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 I i 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 io 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 California." -.. 4 The applicant must call for all required inspections. Complete drawing on reverse side. Signed x 1a: � - 0R PARTMENT USE ONLY Application Accepted by Date Area { Pit or Grout Inspection byDate Final Inspection by Data4�� Additional Comments: 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 AMOUNT REMITTED CASH CKS RECEIVED BY ATE PERMIT'NO. INFO . EH 13-24IREV.v/95S i -EH 14.25 V