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APPLICATION " 1 SAN JOAQUIN COUNTY PUBLIC HEAL7H CES ENVIRONMENTAL HEALTH DIV 5y111��1�� APR 0 4 1994 44s N SAN JOAQUIN, PHONE (209 )4r-9—v20 P O BOX 2009, STOCKTON, CA im ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DAWANVAM 8993 PERMIT/SERVICES (Complete in Triplicat Application 1s hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application 1e made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Countyy PPuublic Health Services Job Address CO AAV — , A — , Coy Lot Size/Acreage c /J Owner's Nam 4 crtAZU � y�—AAdddrreess� �� 1 �c6 ��^ Phone f�AAl �w A ..a r _ Addrets's's'7R�.�aF•K�fti� DLI o'er �^ Conti , ` I ^3 manse N 396 L phon /ro TYPE OF WELL/PUMP: II NEW WELL ❑ WELL REPLACEMENT Cl / DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omeatic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I"I Public ❑ Other fT Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern urface Soul Installed by Repair Work Done Type of Pump �[j,d. Z( H.P. �_-- State Work Dona 'p ILP Well Destruction ❑ Well Diameter Sealing Material i Depth 1 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public Bawer is available within 200 feet.) Installation will "me: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of wil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method vvof�.Diispposal Distance to nearest: Well Foundation Propeny PA �_ LEACHING LINE ❑ No. b Length of lines Total length/si IVED FILTER BED ❑ Distance to nearest: Well Foundation Pro L a SN JOAn1� SEEPAGE PITS 11 Depth Size N�fN rutILIC H�E�ALT" `�' SUMPS LI Distance to nearest: Well Foundation Props rrlam H 1 TIJ n,,,IkZ DISPOSAL PONDS ❑ I hereby cenily that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 no 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 persona subject to workman's comlNnss tion laws o1 Calilorna." The applican/t c I required in tions. Complete drawing on rev ae side. Signed % ( r� -w�' Title: �� Date: go FOR DEPARTMENT USE ONLY Application Accepted by Date Area— ,r ��q�` - Pit or Grout Inspection by Date Final Inspection by fU0 r Date Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Services r- \ Environmental Health Permit/Services UyU 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEAM UNT DUE AMOUNT REMITTED CK RECEIVED BY AT PERMIT NO. INFOt . Ea N 1} IaEV.11hsl �y / r I / f (�I/� ��/ V✓�� rH Ir 24