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p � APPLICATION FOR PERMIT SAN JOA � QUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION AUG 12 1993 445 N SAN JOAQUIN, PHONE (209)468-.3420 P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH ER iRTs YE R M �l )I-� PERMIT/SERVICES (Complete in Triplicate) F - Application is hereby made to gam Joaquin County for a permit to construct and/or install the work herein described. This application is made in cctffPliance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of k Joaquin County Public Health Services, San f Job Address' / E. Ri ware Y t/. Cit Egc.vL sty Y Lot Size/Acreage Owner's Name � V K�rtV<y Address ,$/I: :C G', j Ivc,/ " Phone ContractorrbrA- 5o veo Address & X G s•G 6"4 14ve-, License No. e1�✓„ O',JT7l_Phone r� TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT I-1 r DESTRUCTION ❑ put of Service Well C1 PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well � f DISTANCE TO NEAREST; SEPTIC TANKS EWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation C1 Domestic/Private ❑ Gravei Pack Dia. of Well Casing i I I Public ❑ Tracy Type of Casing_ r!!! Specifications C1 Other n Delta' Depth of.Grout Seal Type of Grout i I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material a Depth De Filler Material i Depth \ TYPE OF SEPTIC WOR NEW INSTALLATION I EPAIR/ApDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.l 4 ` lnataltation will serve; Co►nrnercial Other L hrooeE' (\3 Number of living units: Number of bedrooms 7 _ Character of loll to a depth of 3 feet: 30 ' SEPTIC TANK. Water table depth ,0 Type/Mfg Gaa<, Ltrey CA ` Capacity 1 %Zt'o No. Compartments X _ PKG. TREATMENT PLT:❑ F' Method of Disposal f Distance to nearest: Well 1 o d Foundation �' Property Line LEACHING LINE Rr No. S Length of lines a y a ' Total length/size 6 a ' FILTER BED ❑ Distance to nearest: Well &C Foundption j+o ' Property Line SEEPAGE PITS 11 Depth Site Number SUMPS Ll Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county Ordinances, stat ' rules and regulations of the San Joaquin County , e laws, and Home Owner Or licensed agent's signature cortifiss 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 cenity that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compenu- tion laws of California." 1 F The applicant must call for alt required inspections. Complete drawing on reverse side. 4 Sigrid �_�` Title: Date: 1 FOR DEPARTMENT USE ONLY, 6 4 Application Accepted by Date ao? `� t Area Pit Or Grout Inspection by Date Final Inspection by Data f� Addhlona! Comments; Applicant - Return all copies to; San Joaquin County Public Health Services Environmental Health Permit/Services 445 N Sao Joaquin, P o Sox 2008, Stkn, CA 95201 �/�1 1 FEE AMOUNT DUE AMOUNT REMITTED 1 INFO CK U— CASH RECEIVED BY DATE E-7�1 si3