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APPLICATION QQ #.■■■�G�iiii�� p1glyrb SAN rZAQUIN COUNTY PUBLIC HEAL H>.illiR CES ENVIRONMENTAL HEALTH DIV �l�Il� APR 0 4 1994 445 N SAN JOAQUIN, PHONE (209) 20 P 0 BOX 2009, STOCKTON, CA JaW ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DAVANUZUsessess q993 PERMIT/SERVICES (Complete in Triplicat 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 compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address a„�” Tr r�C City Lot Size/Acreage Owner's Na n� r'J�^ � AddressPhone Contra F � --- --�--- Addreu Ql ��sa-E�-�� Uicense Piton TYPE OF WELL/PUMP: NEW WELL 11WELL REPLACEMENT 11 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omsstic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public ❑ Other Il Delta Depth of Grout Seal Type of Grout I I Irrigation �/—Approx. Depth I I Eastern urface Seal Installed by Repair Work Done I�Typs of Pump 4„ •� H.P. tom_ Sreta Work Oons via Well Destruction ❑ Well Diameter Sealing Material L Depth • r Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo septic system permitted it public waver .a available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of kving units: _ Number of bedrooms Character of wW to a depth of 3 fest: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method ��•�E oLdVof�Disposal Distance to nearest: Well Foundation PropertyBdgT LEACHING LINE LlNo. L Length of lines Total length/si WED _ FILTER BED ❑ Distance to nearest: Well Foundation Pro L e SN IN Ew _ SEEPAGE PITS If Depth Size Nuq/ HE�q SUMPS LI Distance to nearest: Well Foundation Props �,�,pN 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, 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 sob-contracting signatur 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." The applicant r c ILrequired �insf ctions. Complete drawing on in SO side. Signed X ( — � �1--t,Eist''�'� Title: in Date: FOR DEPARTMENT USE ONLY Application Accepted by --- _ Date Area Ph or Grout Inspection by Date Final Inspection by on. Dateki A$ P 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 A UNT DUE AMOUNT REMITTED CK RECEIVED BY AT PERMIT'NO. INFO • EM 1124 IREV.1/1161 EN tt-Zd