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APPLICATION I� 3Tim^ AQUiN COUNTY PUBLIC HEALTH SERVICES D _ ENVIRONMENTAL HEALTH DIVISION t �✓ u Z( r 'T tt 445 SAN JOAQUIN, PHONE (209)468-3420 -- I 'D 11 I q O BOX 2009, STOCKTON, CA 95201 J;U N 1 1994 _ niuyt PE T EXPIRES 1 YEAR FROM DATE ISSUED v tt EIVViRONMENTAI HEALTH (Complete in Triplicate) {y PERMIT/SER%Q u n County for a permit to construct and/or Install the work herein descri E This e v n Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sen Joaquin County Public Health Services. r �Cn/ Job Address I / Jr „1///(�,(�.CtJ (y City 'l Y�/ Lot Size/Acreage — Owner's Name I Address 6 �. L� T Phone Contractor s`/1�>�-� Address A" License No. AL—Sak Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT`S DESTRUCTION ❑ Out of Service Well ❑ .� PUMP INSTALLATION ❑ SYSTEM REPAIR qts, OTHER ❑ Monitoring Well ET DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ r. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing M Domestic/Private ❑ Gravel Pack L) Tracy Type of Casing_- Specifications _ /I'1`Public I I Other (I Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth I I Eastern Su ace Seal Installed by Repair Work Done ❑ Type of Pump H.P. ____ State Work Done _ Well Destruction ❑ Well Diameter sE Sealing Ilii i Depth Depth IAR, IF Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted If public sewer is available within 200 feet.) Installation will serve: Residence_ Cpmmercial^ Other ^ Number of living units: _ Number of bedrooms �\ Character of soil to a depth of 3 feet. I Water table depth SEPTIC TANK ❑ Type/MiQ E Ir+. Capacity No. Compartments (� PKG. TREATMENT PLT. ❑ T.� Method of Disposal Distance to nearest: Well _ Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines - Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line �A t (`\ SEEPAGE PITS [ I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 licen 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 pe rwn i su manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifles the roS1 ,ontlythal in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compares tion laws of CThe applicant ralequred in pe tions. Com e e wing on re a e. Signed itle: Date: FOR DEPARTMENT ONLIY ' _ Application Accepted by Date 6 13 q-- Pit �'��y _ Pit or Grout Inspection by Date Final Inspection b Date 4T Addlita"I 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 W\� FEE AMO NT DUE AMOUNT REMITTED RECEIVED BY DATE PERM17'NO, INFO CASH EH 1434 IRE,.rrxa � / Wyy/tA EH Lpe __ \\ 111 ✓