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r ( APPLICATION FOR PERMIT �s d SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION � ¢Ig P O BOX 2009, STOCHTON, CA 95201 (209) 468-3447 JUN 2 8 1991 PERMIT EXPIRES 1 YEAR PROM DAT TssUEDFNVIRONMENTAL HEALTH (CompleP Application is hereby made,to San Joaquin County for a permit to construct and/or install the workRher Tdtd6mdrVkef.0 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. Job Address rs �- � Nc�?J•7/`7%/�r�,�,,/�7J �/�y � ��.,,��,,,//City7��f ��`�/• Lot Size/Acreage �,`X e-x�� Owner's Name c/kw zzv -yY�r Address a ��/1M w+� �///� W/Y fT/ Phon CxEhin/b� Tr�f/r�ott�`rNc'.,s�/atlf��lf 1�dP.Sr �,rd ,f/ sero. �> qs��i �Zr��a-� Contractor•_ 'l�//t/®'R'A��r1i��Address 2SF l�TCE VZCW l✓ License N0.45f7 51aQ1(9 Pho 8 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT ER ❑ Monitoorrin/g1Well !� DISTANCE TO NEAREST: SEPTIC TANK >`1,,,S0E., 44 SEWER LINES �� DISPOSAL FLD. PROP. LINE sd'1S fi FOUNDATION yroofc AGRICULTURE WELL OTHER WELL PITS/SUMPS f p� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing `-55W `YD Specifications M Public Other `)a3(Delta Depth of Grout Seal q-6-;o!� Type of Grout /✓fir CI Irrigation 42�j.Approx. Depth ❑ Eastern Surface Seal Installed by CLT;7' Pt1!e Repair Work Done L3 Type of Pump NA H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth I3Y 19 MOV- TM)MW& Depth &5 Filler Material i Depth _,1W10p lc ay_r 35' zz to 5-t' l TYPE OF SEPTIC WORK: NEW INSTALLATION ED REPAIR/ADDITION 0 DESTRUCTION CI 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 toil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Ll Method of Disposal ( {� Distance to nearest: Well Foundation Property Line 'I LEACHING LINE C1 No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ti SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line �l DISPOSAL PONDS O 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of Cal or The applic must c 1 for all pactmpleta drawing on reverse side. j q Sign Title:`+'�!/�G ^, FOR DEPARTMENT USE ONLY Appli scion Accepted by � /YIE�� Date 4 Area �32 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: - Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED rCASH RECEIVED BCK d Y DATE PERMIT NO. . EH13-N IREV.ti n sl �(� f76 �9, 52 y� �'� '�'✓� FH A.; ✓ vv