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APPLICATION 00,2 } SAN �AQUIN COUNTY PUBLIC HEATHPC '/�y ENVIRONMENTAL HEALTH DIV J�7 / 445 N SAN JOAQUIN, PHONE (20 ) P O BOX 2009, STOCKTON, C $ 9 PERMIT EXPIRES 1 YEAR FROM D �' rn�vv ED Ifff (Complete in Triplit: Application In 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 Sm Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San I Joaquin County Public Health Services. Job Address -c,(,49 ~'M `""'n a dPYD Lot Size/Acreage NA '73 Owner's Name P��n C r r S BYO L�n Address 0 #��0 Phone —0 �' atntltcre C44g4S9� (707) - i PO-�X 336 ^ Contractor z4Y Address License No. SR�b7q Phone TYPE OF WELL/PUMPS NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ Out Of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER kMonitoring Well E3 HX1DRoPuwcH/ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LI E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public I 1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done C3 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sower is -NONE- available within 200 feet.) Installation will serve: Residence_ Commerciaf_ .Other Number of living units: _ Number of bedrooms Character of and to a depth of 3 test: Water table depth SEPTIC TANK- ❑ Type/Mfg - Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line e f) LEACHING LINE ❑ No. III Length of Cines Total length/size c� FILTER BED ❑ Distance to nearest: Well Foundation Property Lim `\ r SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lim 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 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." id.io. rruJ/n/x4L• .i The applicant must call for all required inspections. Complete drawing on reverse side. p/e&e ria-Ar ><O preappro VEP toorkalk A.. Signed Title: ta�toJ �an�onisf Date: 3-I 6-9¢ FOR DEPARTMENT USE ONLY / Application Accepted by / Date 23 =� ( Area �33 Pit or Grout Inspection by Date Final Inspection by Date Additional Comm m: 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 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE all NO. `' NFO CASH . EM 12.24MIN.rrnml Gyl/,� S'9' �; �s.5� � ZZs `2 2-'38 EM 1420