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APPLICATION .g,. SAN'JOAQUIN COUNTY PUBLIC HEALT"VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 MAY 1 5 1995 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSIIID ENVIRONMENTAL HEALTH (Complete in Triplicate) � PERMIT/SER VICES i Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1 Job Address 15- 1=42T tl�jR�l"lG ��}Y� City .l70CgTGAI Wt Size/Acreage4f/Jt/Z7y2134 -.- Owner's Name /\ !C/faRD �LEW 11 Address 62d Ci",A E�Kc- 68, SACK TQC- Phone C� i BCrJ alA Contractor JOILSc� &At0Ak716d Y6?V CAderess ''�' L License No. .J 26 Phone .S - -TYPE OF WELL/PUMP: NEW WELL ❑ ih WELL REPLACEMENT ❑ D DD Out sof Service Well O PUMP INSTALLATION O !� SYSTEM REPAIR ❑ $OILTBO AQGS ER Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OISPO P. LINE _ -,. FOUNDATION 'I AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Excavation �—1,✓CN Dia. of Well Casing / ❑ Domestic/Private LI Gravel Pack ❑ Tracy Type of asmgfQA Specifications A 1'1 Public ❑ Other fl Delta Depth of Grout Seal �''.Sr7� Type of Grout n'FAT CFME.✓ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by -Sd(LS �XOLd7Y0�.PER✓/CF.1•,.7.✓C. _ Repair Work Done' ❑ Type of Pump ^/ I H.P. n/IA State Work Done_ n/1A t �A Sealing Material a Depth GROUT O' 7a Sd'RGS Well Destruction ❑ Well Diameter ` Depth 'v EL FT ° Filler Material a Depth ----6L 1A TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina ti �A-DISPOSAL PONDS ❑ hereby sonify that I have prepared this application and:;that the work will be done in accordance with San Joaquin county ordinances, state law's, and 11 '. miss and regulatlona of the Sen Joaquin County Home owner or licensed agent's signature canifies the following: "I certify that in the performance of the work for which this permit is issued, I stall not •Po employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature candies the following: "I certify,that in the performance o1 the work for which this permit is issued, I shall employ persons subject to workman's comport". tion laws of CsiFornla" f The applicant must call for all required inspection/. Compete drawing on reverse side. Signed X_ CCTS� Title: IfS,J'0004TFG'FGLOn//.P7" Date: FOR DEPARTMENT USE ONLY x�. i. -',_'_Application Accepted by Date �5-2(� L� Area �� O _' PH or Grout Inspection by .Date Final Inspection by Date .. ^`!Additional Comments: - Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services F 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED I .CASH RECEIVED By DATE PERM11 No. taEV.rr.ar I, EN 14.11 r J �i ,