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APPLICATION SAN AQ UIN COUNTY PUBLIC HEALTH RVICES PAYMENT ENVIRONMENTAL HEALTH DIVISION RECEIVED 445 N SANIJOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 A:U 6 it 2 1993 SAN JOAQtAN COUNTY PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBLIC HEALTH SERVICES (Complete in 'Triplicate) ENVIRONMENTAL HEALTH DIVISION Applications is hereby made to sea Joaquin County for a permit to Construct and/or install the vork herein described. This application is made In compliance vith San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San Joaquin County Public Health services. Job Address a75- GRAM r 4-i N` City %R/aCE}� Let Size/Acreage I7 O7D 5 _Ft {� 11 o Ge bald SPcr�'y _ � Owner's Name Te57Mr1a I/'sJ�f _ Address f�l� Glk�+aP C�tvla/ bl - 5,'K � POhone _r 6r1'r % t o(oa l 0 h u r Ave - 873 Contractor c Address License No.6�7 f hone TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELVi-_/ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing F.1 Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing_ 5pecitications.. -� Cl Public Cl Other n Delta Depth of Grout Seal Type of Grout �F I I irrigation —Approx. Depth I I Eastern Surface Saul installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter sealing Material i Depth Depth Filler Material h Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is I available within 200 feet.) Installation wilt serve: Residence_,.— Commercial Other c Number of living units: Number of bedrooms, Character of soil to a depth of 3 feet: .1" Water table depth SEPTIC TANK. to Type/Mfg. Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal *1 : Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. B Length of lines Total length/size 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 ❑ t 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 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 shell not employ any person in such manner as to become subjecr to workmen'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, t 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, tQif Z \,bigned � � Title: �-�1'E-S Lc __- Date: FOR (DEPARTMENT USE ONLYq . Application Accepted by Date '_Z Area Pit or Grout Inspection by Date Final Inction by f " Date Additional Comments: O r E s LLS f Applicant - Return all copies to: San Joaquin County Public 4alth Services Environmental Healtb Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEO CK 4 CASH RECEIVED BY HATE PERMIT'NO. INFO . EH 17-24 tREV.r/n51 EM 14-20 1 G + {