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APPLICATION FOR PERMIT 2J SANYAQUIN COUNTY PUBLIC HEALTH SERVIC ENVIRONMENTAL HEALTH D IAV I S I ON 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 QC 1993 PERMIT EXPIRES 1 YEAR FROM DATEiiissu IRONMENTAL HEALTH (Complete in Triplic te) I PERMIT/SERVICES 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 and Regulations of San Joaquin County Public Health Services. OAC : ',+: Mon I+$aro Wd1 1 Job Address b� ot l! City N' Lot Size/Acreage (� S p� 1 I Owner's Nemo .2� � ��- Address Phone , Contractor Vs'1i1� Address }( Phone TYPE OF WELL/PUMP: 14EW WELL WELL REPLACEMENT Q DESTRUCTION ❑ Out of Service I1ell ❑ PUMP INSTALLATIO ❑ SYSTE REPAIR ❑� � ,�O��T))HH�E,,R ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES ur 19 DISPOSAL FLUAL1 .� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation IM Dia. of Well Casing r]r� Domesticriv ❑ Gravel Pack 13Tracy Type of Casing_ Specifications ns Public I"1 Other 9Delta Depth of Grout Seat f' I Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Soul Installed by '1 G Repair Work Dane U Type of Pump H.P. I� State Wl ork Done Sealing Material A Depth Well Destruction O Well Diameter y I1 i Depth hiller Material i Depth a ii TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTN I I (No ;optic system permitted if public sewer is available within 200 feet.) .i Installation will serve: Residence— Commercial— Other i Number of living units: Number of bedrooms Character of soG to a depth of 3 feet: Water table depth Ij 1 SEPTIC TANK. ❑ Type/Mfg Capacity � Na. Compartments PKG. TREATMENT PLT.Cl it Method of Disposal 3 Distance to nearest: Well Foundation f?roperty Line t LEACHING LINE Ll No. b Length of lines :Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation I Property Line i SEEPAGE PITS 11 Depth Size [�Numbelr' 1 i SUMPS L1 Distance to nearest: Well Foundation I Property Line 1 DISPOSAL PONDS ❑ I hereby certify that ! 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 -[I ;). I 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 subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is Issued, l shall employ persons subject to workman's compenss- tion laws of California." The applicant must call for all r fired inspections. Complete drawing on reverse side. i Signed ride: Date: 9.1y�93 FOR DEPARTMENT USE ONLY II I 35.4 Application Acc ted by } f Date " Area Pit or Groout In pacWn by f Date yr 3 Fi al Inspectio11 n'by Date C Additional Comments: Applicant - Return all copies to: San Joaquin County Public Healthiservices Environmental Health Permit/Services j 445 N San Joaquin, P 0 Box 2009,'I $tkn„�CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 11 RECEIVED BY-'!,) DATE PERMIT'NO. CASH INFO CASH . EH 1344 IlIEY � 1 1 in�1 .�3 EN I4.26 VJ/ QI �V}/yJ � l V