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�/ g APPLICATION FOR PERMIT q Ire AI o i�6 tlT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' RECEIVED ENVIRONMENTAL -'HEALTH DIVISION r' SEP Q 8 1 1992 P 0 BOB 2009, STOCKTON, `CA 95201 SAN JOAQUIN CO!INTY (209)- 468-3447.' $ I' ~ 8 1W2 Pu; LIC N ALTS s vlc s " " ''`ERERMITNVIR0AUTAL wLALTH ENVIRONMENTALHEAif'riDIVISIO (Complete ita Triplicate) PERMIT/SERVICES Application Is hereby made,to San Joaquin county for a portait.,to�construct and/or install the work herein described. This application is made in compliance vith But Joaquin County Ordinance No. 54q and 1862,and the Rtiloa a.ad Regulations of San Joaquin County Public(Health Services. tl 2150 E. 1 Job Address 2cMa T Sl. ,� - � , - 'C;ty��pC�-�ie/ �� Lot Size/Acreage. Owner's Name ELI,4 f`kM r kr TlZf35 •_ Address-,5000 — Phone d Contracfot5 Addriss a License No.5I2.21v6 Phone -87/Z TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT ❑ ; DESTRUCTION 0 Out of Service Well ❑ o i yori Well ml PUMP INSTALLATION ❑ SYSTEM REPAIR n »� OTHER ®' S'I�tIjor;vt DISTANCE TO NEAREST: SEPTIC TANK A) SEWER LINES /Co ri DISPOSAL FLO. PROP. LINE 'II,FOUNOATION _jar,-- AGRICULTURE WELL & ._ OTHER WEI.L•!��- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � C) industrial © Open Bottom 0 Manteca Dia. of Well Excavation (� �',.�w'p;a. of Well casing Domestic/Private C) Gravel Pack n Tracy Type of Casing � 0 -14gq M Public f Other O Delta. - Depth of Grout Seal 5IIR&4cgE a ,'Type of Grout.�iVC�c T CJ Irrigation ��IZDApprox. Depth ❑ Eastern Surface Saul Installed by 2,4C Repair Work Done U Type of Pump H.P. Y ' State Work Done Well Destruction ❑ Well Diameter Sealing Haterial:i.Depth ,Depth Piller Haterial i Depth TYPE OF SEPTIC WORK:Ii NEW INSTALLATION 0 REPAIR/ADDITION L71 DESTRUCTION G (No septic system permitted if public sewer is II' 7E. available within 200 tea(.)- Installation will serve: Residence — Commercial` Other^ 'I, d tr r Number of living units: 4Number of bedrooms �` ✓�„'. ' 4 Character of soil to a depth of 3 leet: �I r Water table depth - e SEPTIC TANK ❑ Type/Mfg .j Capacity No. Compartments N PKG. TREATMENT PLT, Cl '! F Method oi. D'isposal' Distance to nearest: Well r Foundation ` ? Property Line-. " LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wall Foundation Property Line SEEPAGE PITS I l Depth Size Number - SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ I hereby crnify that I have prepared this application and that the work will be done in accoroance with San Joaquin county ordinances, state laws, and rulas and regulations of the Sen Joaquin County _ " ','l _ Home owner or licensed agent's signature certifies the toliowing: "I canily.that In the performance of the work !or which oils permit is issued, f shall net employ any person in such manner as to become subject to workman's compensation laws of California.', Contractor's hiring or subcontracting signature certifies the following."I certify that in the pertormanee of the work for which this permit is issued, I shall employ parsons subject to workman's componsa• tion laws of Californls," The applica t u all all requir ins clions. Complete drawing on reverse side. Signed ,� ; T4Io- O S L% / 1 Data:, Ii F ,kRTMEtNT USE ONLY ei` Application A6/opted by f Date � �Area -/-33' I 1l1 - P;t or Grout inspection by Date t Final Inspection by Date Additional Comments: : rN ii Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES' ' j �� n F4VIRONg8NTAL HEALTH DIVISION PERMIT/SERVICES V 945 N SAN JOAQUIN, .p 0 13ORi;2009, STOCKTON, CA'85201`' FEE AMOUNT DUE AMOYNT REMITTED INFO CASk REECEEJV7ED BY DATE PERMIT'N0. fH U•II rAIV.I/e71