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APPLICATION FOR PERMIT P-11AYl,l� kN1 i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED ' ENVIRONIMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 0 v T 2 6 1992 P 0 BOX 2009,. STOCKTON, CA 95201 S 14 JOAQU'IN CD IIN'Y III P()BL; HEAL.T'- SERVICES I PE WIT EXPIRES 1 YEAR FROM DATE ISSUIM,V!F?ON�iIENTAL HEALI-;•i DIVISION ii (Complete in Triplicate) ; Application is hereby Stade to San Joaquin County for a permit to construct and/or install the cork 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. E f Job Address _ T�'10 v ^t TO1�► - - -- -- City Sia.k r Lot Si ze/Acreage d• 6 A I, s. Owner's Na e Yw�� r Address 51920 r W 4 V Phone ^o Gt n (.D -[D Pit)e,r (�I /ye} 3�43(B Contractor Vl ieq }`�(tIr ddress Lice she No:�•FfS�361D Phone5!0 TYPE OF WELL/PUMP:I NEW WELL ❑ WELL REPLACEMENT 177 DESTRUCTION ❑ Out of Service Nell 0 I� PUMP INSTALLATION © . SYSTEM REPAIR ❑ OTHER ® •� I�ndro rirtsg Yell L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 5 I - - ail; FOUNDATION AGRICULTURE WELL.,_„-.. _OTHER.WELL PITS/SUMPS INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 3 C7 industrial I ❑ Open Bottom 0 Manteca Dia. of Well Excavation lgs Dia. of Well Casing 'p EI Domestic/Private �, ❑ Gravel Pack ❑ Tracy Type of Casing -_ Mj2u,1P Specifications Il Public iII� n Other I Delta Depth of Grout Seal a" �! �• Type of Grout.."dC C""} I I Irrigation N w Approx. Depth I I Eastern Surface Seal installed by K V i 1 ha t atl Ott 11 r iii Repair Work Done UI Type of Pump H.P. State Work Done _ Well Destruction ❑.il Well Diameter Sealing Material A Depth G Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is II available within 200 feel.1 Installation will so": Residence_ Commercial Other u Number of living units: Number of bedrooms I Character of soll to a depth of 3 feet: Water table depth SEPTIC TANK. 110 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,I C} Method of Disposal Distance to nearest: Well Foundation Property Line I � LEACHING LINE C1 No. 6 Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS , LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS- � 0_ . _ _ _ _ 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♦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-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 Californle.•'.11 The applicant must call for all required inspections. Complete drawing on reverse side. / Signed Tide: Date: ,� � y IMIi S Application Accepted byFOR DEPARTMENT USE ONLY l� ' Date j 1Z- L Area Ate' Pit or Grout Inspection by Z4Date 9//8 3 Final Inspection by ' t Date 0 Additional Comments: II I Applicant - Return all copies to: San Joaquin County Public Health Services S� Environmental Health Permit/Services 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 !/ INFO AMOUNT DUE AMOUNT REMITTED I CASH LVED BY DATE PERMITNO. EM ism Ir1EV.t,Myr g2 -3eo8