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`,. APPLICATION FOR PERS[I T SAN JOAQUIN COUNTY PUBLIC TIS VICES 4 Z!1� — ENV I RONMENTAL HEALTH DI I 445 N SAN JOAQUIN, PHONE (20 42Q P O BOX 2009, STOCKTON, C 9 -r. ,,Ti,:^1, i- -: = - , PMIMIT EXPIRESR )ATV (Complete in Tripl *c, e�1�1�1 Application is hereby made u to San Joaquin County for a permit to construct an INV ren escribed. 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. L Job Address 2a S W. Be vt�1 a w+t h t+�1 T f!lr Iyt City S+-n--k4n y% Lot Size/Acreage o r� Owner's Name ��hevronyJ� Address �/11//7� �WA40;APhone D-0 7Z- �S Contractor s License Phone TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 7 100 SEWER LINES 71170" DISPOSAL FLD.AIWVPROP. LINE -r FOUNDATION 7-JOLIL AGRICULTURE WELL OTHER WELL 7100 t PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tJ * Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cil Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC- Specifications Il Public g0ther fl Delta Depth of Grout Seal ;?=Q/ Type of Grout I I Irrigation 3 Approx. Depth 11 Eastern Surface Seal Installed by1110 DY 11 Repair Work Done U Type of Pump H.P. State Work De _ WeN Destruction O Well Diameter 2 a Sealing Material i Depth NtatL7�/� �><Drl/ �2d & K640e✓46. Depth 35 biller 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 feet.) Installation will serve: Residence_ Commercial_ Other Numbw of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. i Length of lines Total length/size FILT eft oundation Property Line SEEPAGE PITS I I Depth Size SUMPS L! Di est: Weil Foundation Property Line NDS ❑ 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: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to became subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the Wormance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Cakfornla." The applicant for aM requ inspections. Complete drawing on reverse side. p Signed X Title: �`'0 L[nei f2f-- Date: �r 7 ` FOR DEPARTMENT USE ONLY 35 Appkcation Accepted by Date I J Area Pit or Grout Inspection by Date +Q / Final Inspection by Date IC AdditioComments:naComments: OfT_ TC C�YLG�Y([iI S Lkk(t [p/L Applicant - Return all copies to: EnvironmentalJoaquin oHealth Permiunty Ablic t/Services ealth vicea RECEIVED NA7 7 1993 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DtJE AMOUNT REMITTED CK 0 CASHRECEIVED By DATE PERMIT'N0. INFO M Q' . EN 13-24IREV. ,est Z5 2114-314 W v 3 EH 1421 - $