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APPLICATION FOR PERMIT SAN JCak COUNTY PUBLIC HEALTH S71VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 llvll P O BOX 2009, STOCKTON, CA 95201 J A l J 1 7 1995 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 'NVIRONMENTAI.HEAUri Application Is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein descry bed. This application is made in ctspliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 506 CImIg TV, WAV /'',/1 /City STOC,v nk.0- <-r0,V LotLS-iize/Acreage Z� me2" Owmr s Na (Gad �YGI� Address � �• „ 1L� Phone NA_ Contractof6 e5,' Address 3aC�LSj1i 6� " i�� License No.�L>�. ';7—Phone 0-1 451 Aq I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ 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 SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fid. Cl Domestic/Private .Gravel Pack ❑ Tracy Type of Casing Pvc Specifications'�-4�b4ED, 40 f'I Public n Other �P sIta Depth of Grout Seal N 3�� Type of Grout/ytArCE/19G✓ I I Irrigation _Approx, Depth � q I I Eastern Sur/lacs Seal Installed by�IL5 Lh IOW ne LJ \) SFi2 v/cF5 l� Repair Work DoType of Pump /,I H.P. NI'4 State Work Done Well Destruction ❑ Well Diameter Z 1,�Cf1 Sealing Material i Depth 6R9iJT/8-3J FfE�, Bf,?O�✓/7F 31 r�v 31/ Depth ES FFr=T Piller Material i Depth 91:3 54Wz,, �33 -SS FCFT - TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public cower is available within 200 feet.) Installation will verve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of as to a depth of 3 fast: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal , Distance to nearest: Well Foundation Property Lira LEACHING LINE ❑ No. g Length of lines Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lira DISPOSAL PONDS ❑ 1 hereby certify that I haw 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 Horne 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 atoll not anploy any parson in such manner u to becorm subject to workman's compensation laws of California." Contractor's hiring or win-contracting signature drtifies the following: "I certify that in the performance of the work for which this petnit is issued, I shall employ persons subject to workman's compenw tion laws of California." The applicant must call for nN r wed inspections. Complete drawing on reverse side. Signed X_� �`/ Title: AQ SOC tATP Cn c'c Lot 1ST Date: I L-Z3-97 - I FOR DEPARTMENT USE ONLY di Q Application Accepted bVECJ '��`\\""��" Date / z � Area Pit or Grout Inspection by// Q'IA IVNA'1 Date Ib' Final Inspection by Data Additional Comments: —J'4y)'-+ Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 iP 3FEE INFO AMOUNT ye DUE AMOUNT REMITTED CASH RECEIVED all DATE /�PERMIT'NO. kl EH 1324._• EM tall(REV,IranDl 1 r �� L�OJ n