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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES JJJ1d1Yd ENVIRONMENTAL HEALTH DIVISION D D 3 2 1994 445PNSAN 0 BOXJOAQUIN, PHONE 2009, STOCKTON, CA)95201420 FAX (Zoyj 464 p 138 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 costpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Z Job Address ZS CC✓n I (' UVb City (i �ul'��✓f L1ot Size/Acreage 7.`1000 (/ _ Owner's Name 5hewl 04 49a•✓1,dnq Address PO a1,EtZ w 3 C' /Ie'ar /, C4 Phone 10 67 -w Contractor G� �� ✓` Address S.i ff:l Cid 0806 License�No. 6S64o7 p0l ±Z-7-6917 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT i. DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR a OTHER X Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 50 SEWER LINES ,- 5 DISPOSAL FLO. 750 PROP. LINE L FOUNDATION ?L' AGRICULTURE WELL 2100-4 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r/ r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ W Specifications 11 Public T that 71 Delta Depth of Grout Seal goe Type of Grout 11 Imi aeon 1iieAppfox. Depth I I Eastern Surface Seal Installed by r� Repair Work Done L3 Type of Pump IVA H.P. State Work Done ff�ed r, Well Destruction ❑ Well Diameter Zr� Sealing Material i Depth O/A Depth f '+^LLX Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ! DESTRUCTION 111No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil 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 Ll No. i Length o1 lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compansa tion laws of California." The applican must call for all required inspections. Complete drawing on reverse side. Signed Tide: Owner Date: 12-27-94 john / � FOR DEPARTMENT USE ONLY Application A opted Dy 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 FEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EN 2-L4 IRIN irn Sr