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APPLICATION `. ..i' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 PAYMENT P O BOX 2009, STOCKTON, CA 95201 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUID JAN 12 1993 (Complete in Triplicate) SAN JOAQUIN COUNTY Application 1s hereby made to San Joaquin County for a permit to construct and/or InstallC C,, kTAe%�&ESThis application Se made in compliance with San Joaquin County Ordinance No. 549 and 1862 and J&P,EBIdAiaHbAltTkh�IWSII Joaquin County Public Health Services,, Job Address - 1 �� /✓/� —� P4City Lot Size/Acreage Owner's Name rl /�J� Address /►'L- 'L� Phone Contract aJ Addre1, < l) icense -� �� Phone d35_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L1 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR !� OTHER ❑ Monitoring Well LT DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 DED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' Industrial ❑ Open Bottom ❑ Manteca Dia. or Well Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications F] Public EI Other FI Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth 1 Eastern 1 Surface Soul Installed by Repair Work Done yd' Type of Pump r H.PJB _ State Work Done Y"Y Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I 1 Mo septic system permitted it public sewer is available within 200 feet.) l� Installation will serve((: Residence_ Commercial_ Othnr C Number of living u4s: _ Number of bedrooms Character of Will to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 711 LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line V Y SEEPAGE PITS I I Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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." The applicant m t jl fo II required inspec jons. Complete drawing on ragerse side. ryry Signed Title: �;g 6�l Date: —� .J FOR DEPARTMENT USE ONLY Application Accepted by —��LData O Area l Pit or Grout Inspection by Date Final Inspection by Date / -3 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 . N AMOUNT DUE (AMOUNT REkIIITTED ItRECEIVED BY DATEPERMIT'NO.INFO EN IYI0 IREV.r/x51 bie , F5', V. . ' /ZJ ///1