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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES • ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 v P O BOX 2009, STOCKTON, CA 95201 p P R 2 9 1993 PERMIT EXPIRES 1 YEAR FROM DATE ISSIIEO (Complete in Triplicate) ENVIR�OpN�fM/ECNTTALHEA(TH Application 1s hereby tmde to Sam Joaquin County for a permit to construct and/or install the work he Pe fii"dAAt' &VLCiE&hic application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. JobAddresa .� :Z �' )CVT2"� Lot Size/AcreageCiy Owner's NameA A44yc — Address ,! All _.P, ,Phone % Contract Address W ,cense No. Phol �J�Z� TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT a DESTRUCTION ❑ Out of service Yell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications— Yl pecifications Pl Public Ci Omer Cl Delta Depth of Grout Seal Type of Grout +N1 I i Irrigation _Approx. Depth I I Eastern Surface Seal Installed by V Repair Work Done ❑ Type of Pump H.P. State Work Done_ -9 Well Destruction ❑ Well Diameter Sealing Material i Depth d Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRrADOITION DESTRUCTION I I IN.septic system permitted if public sewer is • 9 Installation will serve; Residence-Y, Commercial_ Oiavailable within har _ 200 teet.l dr4 et[. —•Ska"r, b Number of living to aa: t_ Numbs bad ACA m u-a-<5�5 `I �� S.table .aG '}y Character of soil to a depth of 3 feet: T`^�` Water table dap SEPTIC TANKhjj—`0 Type/ Mfg np � �� Capacity No. Compartments PKG. TREATMENT PLT. LlA960T .�}tx...-e•- Method of Disposal Distances to nearest: Well Foundation Propeny Line LEACHING LINEBOe7 l N . 8 ength of lines Total length/size FILTER BED 0 Distance to nearest: son Property Lira SEEPAGE-PI/TS^., ``II 11 Depth. rt".C4Si a Number SUMPS /Y Ei >k Distance to marital: Property Line 1� DISPOSAL PONDS O 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 Sen 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 subbct to workman's compensation laws of California." Contractor's hiring or sub-contracting signature conifers the following: "I certify that in the pertormance of the work for which this permit is squard, I shall employ persons subject to workman's compenaa. tion Tawe of California." The applicant must c/ -�"�i for all require inspecti na. Complete rswing on reverse side. --� Signed / a .6/��i Title:— Date: F R DEPARTMENT USE ONLY - Application Accepted by O raffia 'M ! F% st I'Ap QAysa Date Area CJZ--- Pit of Grout Impaction by Oats Final Inspection by pate 143 Additional Comments: �- /.2 • Applicant - Return all copies to: San uin County Public Health Services ,$/y Environmental Health Permit/Servicers 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASHEH /.D 1 p� �/i EH tw•m,REV.rrn err J �"/ l �� p /