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A-PPLIC:V1'I ON `. t PAYMENT SAN;'JOAQUIN COUNTY PUBLIC !lEALTE SERVICES ENVIRONMENTAL HEALTHJ D I V I'S I ON RECEIVED 445 N SAN JOAQUIN, PHONE :'(2091}468-3420 F E S 16 1993 P O BOX 2009, STOCKTON;', CAI 95201 j SAN JOAQQUIN COUNTY PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBHC HEALTH SERVICES (Complete in Tr1plYcate" ) ENVIRONMENTA14 HF-ALIH DIVISION q I: 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 sad Regulations of San Joaquin County Public Health Services. /� YOO IM Job Address PV �0 City OC od7 Lot Size/Acreage 2 03 Owner's llama �N /�e i7 gee - aia�Address ��t� �//uf >�� Phone6 �/[�(v 't1�c'd 'i �� s • Contractor S fS DC/�1f Address l/ /Qy�ar l^�Por�gT`oM License No.��J yip �o2Phone�5/ yG.�-�/d� 44 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,F n 1I DESTRUCTION ❑ Out of Service Well ❑ V: PUMP INSTALLATION O SYSTEM REPAIR, C1 �If OTHER X S�Ngn `orAng Well C7 DISTANCE TO NEAREST: SEPTIC TANK A//9 SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 3 SU PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F.1 DornesticlPrivate Cl Gravel Pack 0 Tracy Type of Casing_. Specifications I'I Public X Other n Delta Depth of Grout Seal 7S Type of Grouth /+ea�Ce � i y I I Irrioation 7�.Appfor. Depth I I Eastern Surface Saul Instdllad by CfS,� F- sso��ut-s Repair Work Done U Type of Pump H.P. i State Work Done Well Destruction O Well Diameter Sealing Material i Depth iM Depth Filler Material i Depth1 IN TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 111 INo septic system permitled if public sewer is 'I available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units. Number of bedrooms II Character of soli to a depth of 3 lest: i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity II !R No. Compartments PKG. TREATMENT PLT.❑ j k Method of Disposal Distance to nearest: Well Foundation I Property Line A y LEACHING LINE Ll No. ii Length of lines I Totai'lFength/size v f FILTER BED 171 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size II Number SUMPS Ll Distance to nearest: Well Foundation r} i.k 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, and rules and regulations of the San Joaquin County p Home owner or licensed agent's signature canifies the following: "I certify that in the periormance'of the work for which this permit is issued. I shall not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring of sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is it sued, I i`hall 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/l 'Signed X „_. Title: 5tU �yc-�lo /sem Date: �} .{ it FOR DEPARTMENT USE ONLY '� ST i Application Accepted be,151A Date 'i Area Z.!G /�. v 0 Pit or Grout Inspection by Date -942 Final Inspection by 11 Data Additional Comm.nta: 81DL PAP2 Q{^ptJi 123 .93 .__ SID)'662 'l QroiJkd Applicant - Return all copies San Joaquin County Public Health Services � Environmental health Permit/Services; 445 H Sari Joaquin, P O Box 2009, Stkn!P CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BYll DATE PERMIT'NO. H 1/ EH 14�Ze 21111EV.ri9>si g . �� 9. D� 35 _ __ • �y 93 ZL�S�o E