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• APPLICATION • A g c `13� C0.O 7j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES L� p ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 rI C P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to San Joaquin County for a permit to construct and/or install the work 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. 1 Job Address IZ7Aw`-RAC* /�tt sk qy City TRMcT Lot Size/Acreage Owner's Name umt+c-d Address IjAIX� Phone Contractor Address • � SrC rYAr_ \4Isco License No.44S1bS Phon 1 TYPE OF WELL/PUMP'. NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION *.Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ig' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE --l.' 4' 13 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �f'Y� Otla INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS o ❑ Industrial ❑ Open Bottom ❑ Manteca Diaqthf ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy TVa g__ Specifications I'1 Public ❑ Other fl Delta De r t Seal Type of Grout I I Irrigation __Approx. Depth 1 I Eastern Suoul Installed by Repair Work Done ❑ Type of Pump H.P. __ State Work Done_ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Materiel & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted it lic sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other ;_,, Number of living units: _ Number of bedrooms :aJU Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Cap city No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ` LEACHING LINE ❑ No. & Length of lines Total length/size - FILTER BED ❑ Distance to nearest: Well FounctIion ,�J� Property Line SEEPAGE PITS 11 Depth Sire gyp/ nr_umber SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ 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, 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 California." The spplic nt must c II for all req fired nspections. Complete drawing on reverse side. Signed Title: ceito f. :2r-- Date: /O-3U-96 _.� FOR DEPARTMENT USE ONLY c 9 Application Accepted by " y ' �C��'� Date ✓ ` l ( Area Pit or Grout Inspection by Date Final Inspection by �l I� Date exll Z Additional Comments: a 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 INfO A/M�O`UNT DUE AMOUNT REMITTED 'ASM��6 RECEIVED BV DATE PERMIT'NO. EN 13-24 IREV,Iin5i ��y{ — `��/t oJ=? �� Ol�� Page I3A