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i ri. APPLICATION ..► SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION DEC 2 81994 445PNOSAN JOAQUIN, PHONE STOCKTON, CA)95201420FfIX(zo9) 464-D13$ ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (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. �srS //�� ff I / Z. LS L+1 r-r\/yyipl� P�n�d City oae- 0,, Lot Size/Acreage IZb 0 Job Address 1 (�/ S P/'YIGCP 11L�^ OrL( lw�dtl ass 2T,4q�Lh 7Eyi-kh) n Phon 6S O i Owner's Name _A�m1 %15 ZI/41 \ Fo-+d.rr W:l i�wl MrnrG`9�S tvs ✓� c-, T !v z ConUactor ems. � r 'n Address fi fi a90E Licr se NO. 6564 7 on�4Z7-fig�l TYPE OF WELL/P P. NEW WELL ❑ WELL REPLACEMENT ["l DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C. OTHER X Monitoring Well Li DISTANCE TO NEAREST: SEPTIC TANK >5-(9 SEWER LINES 7> O DISPOSAL FLD.1 5-0 PROP. LINE II Ll FOUNDATION 3G ' AGRICULTURE WELL �ldoJ OTHER WELL15-CO PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y / it Industnal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation L ' Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing_ yV,6 Specifications i'I Public ,Other 7 Delta Depth of Grow Seal Type of Grout I Cl4e,,2 I Irngabon « Approx. Deptth ( I Eastern Surface Seal Inseliad by T Repair Work Done ❑ Type of Pump •' M.P. State Work Oona Well Destruction ❑ Well Diameter n Sealing Material a Depth 1)/14 Depth r�Jr ivt�aY Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION ! DESTRUCTION I I (No septic system permitted if public Bawer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: _ Number of bedrooms Character of wit to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED 1-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby comity that 1 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 compents tion laws of California." The applicant usI call for all required inspections. Complete drawing on reverse side. Signed Title: Owner Date: 12-27-94 ^InFOR DEPARTMENT USE ONLY Application Accepted by t Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 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 Kill FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EM 17m�IaEV.".,l