FIELD DOCUMENTS AND WORK PLANS 1992-1999

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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 _PERMIT EXPIRES I YEAR PROM DATE ISSUED QA S{TC (Complete in Triplicate) OR(- Application is hereby made to Ban Joaquin County for a permit to construct and/or install the vork herein described. This application Is made In compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public He�alth Services. '1 Job Address �'sp r•A 'S'1AJC4A1k AVE. (R4fJ9Z1/ City (5TO'L�DklLot Size/Acreage A11,W-LE/ coa�y�G �n9 Owr»r's Name YJ»A Fz2 C11AbiA-N`I Address /SO A( S11VCLRJ� Off• Phone (0� 3 S/ p,D. BoxSa53a' .Df3� 0-59� 610 Contiaclor Rl✓'i- WAS WEU 8tfZa dress 614160-5ry&P2CA.9 � License No. 1'013-37 Phone 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Ll Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIPNS - PIE-}SE SEE n6t)a 2- ,X 6-0-p;,❑ Open Bottom (5Manteca Dia. of Wall E...vanion_2`P � Dia. of Well Casing 91 9y Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ SJAL<L Specifications FI Public XOther MI)AILTM n Delta Depth of Grout Seal /Sa Type of Grout C I I litigation _.Approx. Depth I I EasternSurface Seal Installed by AVRL W61fK I441L Repair Work Done ❑ Type of Pump59&-9A6Lf H,P. VY; State Work Done _ Well Destruction ❑ Well Diameter Bawling Material A Depth , Depth Tiller Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public waver is available within 200 last) Installation will sat": Residence_ Commercial_ Other Number of living units. _ Number of bedrooms Character of sa to a depth of 3 fast: Waist table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to merest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to merest•. Well Foundation Property Lina DISPOSAL PONDS ❑ I hereby conity that I haw prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rums and regulations of the Sen Joaquin County - Home owner or licensed agent's signature certifies the following; "1 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 subcontracting signature candies 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 CalNornle." The applicant must call fr ed Inspections. Complete drawing on rover" side. Signed x_ 5 5Title: ; n7C-CT /r<��LL/Ct�O[,OPr/� Date: 3 e4VC4 D • ! �� 1G S U EJ) /AK. FOR DEPARTMENT USE ONLY p Application Accepted by ��+�'�`"'"`�I Dais ,.. .' Pit or Grout Inspection by ,•/ Date Final Inspection by Date ✓V Additional Comments: M - �yS ("ro lLp AnTlarr- we l b£T1T/F/EP) Applicant - Return all copies to: San Joaquin County Public Health Services Y ti Environmental Health Permit/Services �,f V/7•�7f ,, 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEECK 1 INFO 'AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PfRMR'NO. 03 i . Fa t04[REV.11.51 /7 %' 012 y� 1�1� rig� 3 93"lSb