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r 4 APPLICATION FOR PRRNITt4,, SANJOAQUIN COUNTY PUBLIC HEALTH SERVI �� ENVIRONmENTAL' HEALTH DIVISION '•i ' , 445 N SAN JOAQUIN, PHONE (209)46$-34 1! PO BOX 2009, STOCKTON, CA 95201 AUG. 0 5 1993 PERMIT EXPIRES X YEAR FROM. DATE .I _SUED •� (Complete in Triplicate) ENVIRONMENTAL HEALTH PERMITISERVICES Application ii' hereby mede•to San Joaquin County for s permit to construct and/or install the work herein described. This application li'.m"e In Coeipllsnce vith San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Fubllc'11ealth Services. ` r � Job Address FI , 1 C L Vim' City �'O �' Lot Size/Acreage _ Owner's Name .Ntrf _ Address �Z �Dr'7 �'OD] I E— Phone uct �'3 �-3ar -�� I C7 C0#90 Conlractor_r�`}I f D" tOL-AMdress 3L+41. r z5erd- o �MtL�r License No.1k Pttone 1 V' TYPE Of WELL/PLIM NEW WELL-7. I WELL REPLACEMENT C i �1 / ' DESTiiUCTION C# Out; of Service yell ❑ PUMP INSTALLATION-❑ r SYSTEM REPAIR 0 OTHER p Monitoring Well n �. DISTANCE TO NEAREST: SEPTIC TANK `' SEWER LINES -Sib Ef "4'DISPOSAL FLP. PROP. LINE , FOUNDATION S -_ AGRICULTURE WELL OTHER WELL C I✓r PITS/SLIMPS- _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS aft C7 Industrial Open Bottom a ,L7 Manteca Dia. of Well Excavation Y Die. of Well Casing {Qoomestic/Private. Gravel Pack Ei Tracy'' Type oVCasing_;_ C $6flail �O Specifications •OZO SC_r_f&A+ I'1 Public ' ("l Other f1 Delta Depth of Grout Seal all, T eLe i L.lfv . Type of Grout I I Irrigation I! Approx. Depth K Eastern Surface Seal Installed by G t%t /C 90K Repair Work Doris .13 Type of Pump H.P. � � State Work Dona a `"`O Salig,Mteril Depth 'DewRN m -IO Well Destruet`be -. Well OismeTiller Material'& Depth TYPE OF SEPTIC WORK: ''NEW INSTALLATION I 1 REPAIRiADDITION i I DESTRUCTION_ I I INo septic system permitted il-public sewer is' • available within 2W lest.) Installation will Terve: Residence __ Commercial Other Number of living units: Number of bedrooms Character of soll to a depth of 3 feet: r , Water table depth SEPTIC TANK " C1 1.Typa/Mfg fi Capacity No.Compartments:1 PKG. TREATMENT PLT. ❑ � � r Method of Disposal Distance to nearest: 40 Well foundation Property Line . LEACHING LINE.;, ❑ No. 4 Length of lines Total length/size FILTER BED ' ❑ Distance to nearest. Well - Founds tion . Property Line f st fF:; SEEPAGE PITS ' It . Depth Sire .� Number SUMPS h L1 Distance to nearest: i Well - Foundation Property Line + DISPOSAL PONDS ❑ I hereby certify th+t I have prepared this application and that the work-will be done in accordance with San Joaquin county ordinances, state laws, and ruler,and regulations of the San Joaquin County Home owner or Iitensed agent's signature certifies the following: "I certify that in she oeriormence of the work for which this permit is issued. t shall not employ any person in such manner as to become subiect to workman's compensation laws of Californis." Contractor's hiring or sub-contracting signature Wnifiss the following: "I csrtity that in the parformance.of the ork for which this'parmit is issued, I shall employ persons subject to workman's compensa• tion laws of California." 1;r a• A The applicant "st afl far all► squired inspections. Complete drawing on reverse side... i Signed fL_ h _ Title: Date: v h --- FOR DEPARTMENT USE ONLY r 35.00 Application Accepted by Q&IdAia Dais Area Ph or Grout InspicWn by Date Final Inspection by Oat@ `h � � / Additional Comments: �' ,CSC a I .Applicant:,- Return all copies o: San Joaquin County Public Health Services S Environmental Health -Peemit/services 445 N San Joaquin, P O Box 200P„ Stkn., CA 95201 .iii. - - - ., _. r; _ ^�•�, E ` AtyiQt/NT C.t'E AM0uPjT ki:M1:•fFp S SW s'EC.I\ b (tr ,NfO' a:stsid AxoLaillksk '= . - '�!.3s a• 4__: .aJT_