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INN A-PPLIC-VI'l'ON SAN 'JOAQUIN COUNTY PUBLIC I1EALISERVICES �� ENVIRONMENTAL HEA.LTR DIVISION I RECEWED 445 N SAN JOAQUIN, PHONE I,(2091)468--3420 FE 8 1 6 1993 P O BOX 2009, STOCKTON�, CA':M 95201 SAN JOAQQUIN COUWY PERMIT EgPIRES 1 YEAR FR if DATE ISSUED PUBLIC M HEANTALHF- SERLTH0C�.S (Complete in Tri f eats) � EAIViRflNMLNIAI:W�ALIH pIV11�16N P P Application In hereby made to San Joaquin County for a permit to construIct and/,or install the work herein described. This application is made in c=*11ance with Sart Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health Services. _® l .1 Job Address 10fV1190 ��A City f DC oli/ Lot Size/Acreage 2 Q,3 I Owner's Name V9W Ao? 1Z Aef!!�94 F04AAddress __1�d0 Phone� V A/- 1 Contractor -W f e Sg OC/`-Ies Address License h1o.GS2 4y, C'9ryp2Phone&! f'G�-�/�GIP TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT' I-i 11 DESTRUCTION CI Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR' L7 OTHER 1KidQn torirtg well ,5 0// cnel HIJ!" DISTANCE TO NEAREST: SEPTIC TANK Al SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL iso PITS/SUMPS # INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing f.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ f Specifications Il Public Other Cl Delta Depth of Grout Seal Type of Groutp9rJ°/__Ze- i 1 1 Irrigation 7 Apptox. Depth I I Eastern Surface Seat Inst.,thed by6,5;4SSe,e-l- --J' Repair Work Done L3 Type of Pump H.P. State Work Dana _ k Well Destruction O Well Diameter Scaling Material i Depth Depth Filler Material i Depths TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I!�I iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 lest: } a P Water table depth SEPTIC TANK ❑ T e/Mf Yp g Capacity Il 1!0 Na. Compartments PKG. TREATMENT PLT. ❑ II Method of Disposal Distance to nearest: Well Foundation �{ Property Line )I Q LEACHING LINE Cl No. & Length of lines °1 Total length/size j FILTER BED 0 Distance to nearest. Well Foundation :i Property Line o SEEPAGE PITS 11 Depth Size Numkier SUMPS LI Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be dons in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County i1 Home owner or licensed agent's signature certifies the following: "I comity that in the perlormance'of the work for which this permit Wissued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring at sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I ahail employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. i,. I I Signed X Title: sf�f lr�lisr _ Date: 1��/93 FOR DEPARTMENT USE ONLY �y 5T Application Accepted by . -/ 3 � .00 ;} Date Araa I Pit or Grout inspection by Date Final Inspection by Data Additional Comments; �1 Applicant - Return all copies to: San Joaquin County Public llealth Services omm } Environmental Health Permit/Services 945 N San Joaquin, P O Box 2009I,; Stkn, O CA 95201 ! � 4 l' 1FEEO AMOUNT jD�UE AMMjOUNT REMITTED CASH RECEIVED BY' DATE PEERMIT'NO. jkr( • En 14-20EM 13-24 IREV.I/a'Sr V / ✓V ii �" ! � .( �; ai