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APPLICATION FOR PERMIT D ow SAN O QUIN COUNTY PUBLIC HEALTH SERVICES ENVIRON11ENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 AUG 19 1993 P O BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) 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 mde 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 40/ w' 16#r t fit" &or- City Lot Size/Acreage t/4 4�t. Owner's Namey`r r.0.1 At - Addresses 57x5- IJ 7N r r01rf l fld'26r%t 4'+4 s phone(?J4 2^O Z4 J Contractor r"�0� •te !'t r t- Address #fE#td• 60AWA CA ZE14-26 License No.4-4 2 7-0 Phon t4S%- f TYPE OF WELL/PUMP: NEW WELL fit WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES >54 f4 DISPOSAL FLD.,o 4 PROP. LINE/0— 0 FOUNDATION?°-fie. AGRICULTURE WELL ;�F_GP OTHER WELLSe'Le' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L-1 Industrial ❑ Open Bottom0 Manteca pia. of Well Excavation /O rw Dia. of Well Casing 4 r� n Domestic/Private PGravel Pack ❑ Tracy Type of Casing Sd-¢ AV5- Specifications $cEK f —� I'I Public Cl Other n Delta Depth of Grout Seal # Type of Grout a tu►e4 O I I Irrigation L!Ely'Approx. Depth I I Eastern Surface Seal Installed b Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it pubfic sewer is + available within 200 feet.) i Installation will serve: Residence_ Commercial_ Other Numbs of living units: Number of bedrooms Character of soli 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 UNE Cl No. A Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I haw prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regutationa of the San Joaquin County Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, l 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 Wormanco 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 crani required inspections. Complete drawing on reverse side. Signed ",.L-.e C.l eel-, Title: a Date: e I2 S FOR DEPARTMENT USE ONLY _ Application Accepted by Data L Area Pk or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Puis Health Services , Environmental Health ermit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED )CASH RECEIVED 0Y DATE 113`17361 PERMWNO. . EH 13-24IIIEV.r/ns) 8 Q1 °J J eZJLg EN 11.26 O