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APPLICATION ''FOR PERMIT " SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIZ ENVIRONMENTAL HEALTH DIVISION a 445 N SAN JOAQUIN, PHONE (209)468-34 P O BOX 2009, STOCKTON, CA 95201 AUG. 0'5 1993 s PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Complete in Triplicate) ENVIRONMNTALHI=AALTM PERMIT/SERVICES Application is hereby made•to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in ccmpliance vith San Joaquin County Ordinance No. 549 and 1852 and the Rules and Regulations of Ban Joaquin County Public--Health Services. 1/ a d' 1 b �- r2,0 4 G �� C. It-() Lot size/Acreage Joh Address Ciry I� Owner's Name �` +' l L Llf� Address f 1 - PhoneVOL �`t ~✓'�!�3 � - UrY?E✓_ D fie� 4ddress �t j l e.I-'IC� M!S }License No, �62}� '} Phone l - Contractor -- TYPE OF WELL/PUMP: MEW-WELL"i WELL REPLACEMENT Fl1 DESTRUCTION Cl Out of service Well ❑ PUMP INSTALLATION C1SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L3 t. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _50 fif DISPOSAL FLD. PROP. LINE 11 FOUNDATION 5 AGRICULTURE WELL OTHER WELL O PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1. �it Cl Industrial ' ❑ Open Bottom L-1 Manteca Dia. of Well Excavation Dia. of Well Casing E SGV 'SFo S .OZO -AJ '�,Domestic/Private � Gravel Pack [� Tracy, Type of Casingspecifications I'll Public II Cl Other fl Oepa" Depth of Grout Seal 'Type a}:,Grovt a? I I Irrivalion II Approx, Depth K Eastern Surface Seal Instarlgd by Repair Work Done U Type of Pump H.P. State Work Done t- Wall psstruttlori' ❑ Well Diameter �� Sealing Material i Depth 93��iy11- f0 Depth ° Filler Material i Depth3 TYPE Of= SEPTIC WORK: NEW INSTALLATION I } REPAIR/ADDITION I I DESTRUCTION I I INo septic system perrriitled if public sewer is ;I available within 200 feetA ` Installation will serve: Residence — Commercial_ Other N Number of living units: Number of bedrooms Character o1 soil 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 LEACHING LINE. ❑ No. 6 Length of lines Total length/size (� FILTER BED �� ❑ Distance to nearest: Well Foundation Property Line In SEEPAGE PITS' 11 Depth Sire Number lQJ SUMPS LI Distance to nearest: Well Foundation Property Lina ° DISPOSAL PONDSI ❑ 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 r, Home owner or licensed agent's signature certifies the following: "I certify that in the perlormance of the work for which this permit is issued, I shell 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 io workman's compensa- tion laws of California." NI The applicant Ohust #11 for �all �required inspections. Complete drawing on reverse side. Signed X [�Gt�.r�v-� Title: ��L' Date: f zZ—V3 3 FOR DEPARTMENT USE ONLY Application Accepted by Date r Pit or Grout Inspection by Date Final Inspection by ate Additional Commenis: Applicant- ,Return all copies to; San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 F EE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE "PERWV NO- :H r3-24(REV.r i e 5) - 'H 142a