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+ APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN J09QUIN, PHONE. (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ` PERMIT -EXPIRES 1 .YEAR FROM DATE. ISSUED (Complete ^in Triplicate.) Application is hereby made to San Joaquin County for a permit to: construct and/or install the work herein described. This 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. Job Address 2-) (o LQ [ Y t/ City. I—0z) I Lot Size/Acreage .11T Owner's Name a n t kt 0�J Address 2 a 6117-"O E Z"C L �- ' Phone Contractor (��u�1T 51 E�-lZ�=Address _7MO '9&by1b D 4/ Liz} bcense N0.61 Phone20a- ?St'9 7 TYPE OF WELUPUMP. NEW WELL� WELL REPLACEMENT tl DESTRUCTION ❑ Out of Service.Well. ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring,Wel.l. DISTANCE TQ'NEAREST: SEPTIC TANK SEWER LINES �01 DISPOSAL FLO. - - PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS, INTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (. L1 Industrial i❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7 .Dia. of Well Casing ?/ [l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of.Casing AV'G Specifications Ih I'] Public other n Delta Depth of Grout Seal r"f'S Type of Grou!t I1 Irrigationl '75—Approx. Depth Eastern Surfaca;Seal Installed by S I; Repair Work Done 17 Type of Pump H.P. Statri Work Oana n ❑ Well Diameter _ Sealing Materiel & Depth (\ Wei! Destruction +Depth 75 Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION 1 1' DESTRUCTION i I (No septic system permitted if public sewer is {� available within 200 feet.) Installation will serve: Residence__.,_, Commercial T Other Number of living units: Number of bedrooms Water table Character ofi'eoil to a depth of 3 fest: depth SEPTIC TANK" ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well :Foundation Property Line j LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth - Size Number SUMPS f Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, an 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 parson 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 Cal'ornia." The applicant ust It fora a aired inspections., Complete drawing on reverse side Signed Title: "t f s� Date: 3 F. FOR DEPARTMENT USE ONLY ST Application Accepted by Date Area. Pit or Grout Inspection by Date4-12-93 Tinel nspection by Date k Additional CommenU: UTT 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 INTO AMOUNT DUE AMOUNT REMITTED SH,E RECEIVER BY DATE PERM 'NO. 1. k' EN�: ;rt . �q. q3-05ar , .