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APPLICATIONIFOR PERMIT It SAN* AQUIN COUNTY PUBLIC HEALTH S ICES � i z ENVIRONMENTAL HEALTH DIVISION `7 1601 E. HAZELTON AVE. PRONE (209)468-3420 P O BO% 2009, STOCKTON, CA 95201 APR ] 3 1093 PERMIT EXPIhES 1 YEAR FROM-DATE ISSUBP ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is hereby made to San Joaquin County for a permit to construct and/or Install the York herein described. This application is made'!in cotapiisnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 160577 - G L DDIC4DO.S-r _ City_S' 'I). Lot Size/Acreage TX ACRE Owner's Name CO /7w usA Address R-0-@Q c!T q15 N. -]JC M/0-11 hone Contractor fail IA Address—R-0, 60� 3346 . License Na.Ml n' : «Phone 70 .3 TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service well Cl PUMP INSTALLATION O SYSTEM REPAIR '❑ OT ER Cl Monitoring Well 1(. DISTANCE TO NEAREST: SEPTIC TANK �1 SEWER LINES �0 DISPOSAL FLO. N PROP. LINE FOUNDATION AGRICULTURE WELL —4L4— OTHER WELL -' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1Y. N%ft.% Dia. of Well Casing �A Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing -3C _ s'1FQ PVC __-_ Specifications KPublic ��.O�/ther n Delta Depth of Grout Seal 3� P& ype of Grout S S I I Irrivation Vs-lie-L Approx. Depth l I Eastern Surface Saul installed by— (Mina 12a 1.i.49 4 Ca. Repair Work Done 0 Type of Pump IIIA H.P.. State WOrk.Done ._ Well Destruction ❑ Well Diameter Sealing Material 8 Depth Depth Filler Material i Depth U TYPE OF SEPTIC WORK: NEW INSTALLATION I.I REPAIR/ADDITION 1 I, DESTRUCTION t I lNo septic system permitted if priblic sewer is " available within 200 tast.l (� Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. '❑ Type/Mfg l.capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well foundation Property Line' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line C SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well foundation Property Line r 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 IicanseC agent's signature certifies the following: "I certify that in the performance of the work for which this peimit 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: '1 canify that in the performance ol.the work for which this permit is issued. I shall employ persons subject to workman's compertsa- tion laws of California." The applicant7XI r aluired inspections. Complete drawing on reverse side. Signed Title: �7ic7 7-.. l`C_J/a _ffJ . Date: L/ FOR EPARTMENT USE ONLY 3 Application Accepted'by Date I Area �" Pit or Grout Inspection by SIn a ��3 Final Inspection by Date Additional Comments: �` c.w Applicant - Return all copies .tot San Joaquin County Public Health ^0 Services, Environmental Health Permit/Services Q u 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 9 FEE AMOUNT DUE AMOUNT REMITTED KRECEIVED BY OATS PERMIT" INFO CASH . EM.53.21IAEV.r��sr�� 6vo I - A±r . 1