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APPLICATION 1 JZ-4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 � �` �� 40i MAY 0 5 1994 P 0 BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) Application is hereby made to Seo Joaquin County for a permit to construct and/or install the work herein described. This application is made in cotapliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sen Joaquin County Public Health Services. Job Address - 14:0 FF_F_SN0 City f2MC4;f�D1�J Lot Size/Acreage fPlJ /(03-3�-/9 owner's Name �C� ' �� Address y a Vim❑= Z'-W:> t"At It2=R � J r Phone ZC'l -` Z • 7bu yt�,U7l�3r t'1�� Contractor int r't__�^'�-��- - Address MIA(-LE S; License No. Phone 20'1•9 °13' TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 5 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well �j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Z ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_Za 5Ut `t $1ft- Specifications- 1'1 Public I-] Other n Delta Depth of Grout Seal Type of Grou1L13NpJ.>` '�'176'Y I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material L Depth ,i TYPE OFSEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION 1 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 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size O FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 person 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 California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed _L Title: STS E1.1611.1 _ Date: 515.1yl FOR DEPARTMENT USE ONLY Application Accepted by DateAre, 02 Pit or Grout inspection by f�T Date _ 3 final Inspection by Additional Comments: IF Applicant - Return all copies to: San Joaquin County Public Health ServicesEnvironmental Health Permit/Services445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO /A�MOUNTT DD�UE AMOUNT REMITTED CK 9 CASHRECEIVED By DATE EH ta-211REV.1/x51 /1 ,/y 7 ' .. /b d�EH 11.2e E/ V_/ ( -(