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ti anPLIC'.OTON SAN JOAQUIN COUNTY PUELIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 AUG 16 1993 P O BOX 2009, STQ TON, CA 95201 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERM ITISERVICES (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to iconstruct 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. Job Address 42(1 We-5+ Loc.kd' ed StfCCity � Lod t Lot Size/Acreage •Z d f X n Owner's Name W. MG�� W", V I cili Address `1 At Lcr- " '4 St' Lod Phone VVI 0014 C4 CA Contractor(st'a V siP _n100"h°t'1Address 10422 P ye4- License No..4 1()4-9+ Phon l)o4 '1'1733 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ci Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEMREPAIR C7 OTHER Mortiitoring Well E� 3 sot �or;r,CJiS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Ste# DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ID Open Bottom ❑ Manteca Dia. of Well Excavation r' Dia. of Well Casing NA (.l Domestic IPrivate ❑ Gravel Pack C1 Tracy Type of Casing_ NA Specifications NA I'I Public Cl Other n Delta Depth of,;Grout Seal N A Type of Grout 1 i I Irrigation �.Approx. Depth t I Eastern Surface Sedl Insta tied by N A 1' Repair Work Done U Type of Pump H.P. State Work Qone — Sealing Material & Depth Well Destruction ❑ Well Diameter Gel+1 �✓' }tiR II i Depth Filler Materi.al1 Depth i� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I `DESTRUCTION I I (No septic system permitted if public sewer is t available within 203 feet.) . it Installation will serve: Residence_ w;. _... Number of living units: Nu Post-It"brand fax transmittal memo 7671 #or pages Character of soil to a depth of 3 lei To Fro s,ldepthi SEPTIC TANK ❑ Type/fv Errs ►' I sttments Co. Co: PKG. TREATMENT PLT, G7 Cj C� , ;rj"3G A Oiisposal ( 7 Distant Dept. t� Phone# Fax# Fax LEACHING LINE ❑ No. a I FILTER BED ❑ Distant_- ._ I , SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Count Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work'ifor which 4thi5'permit is issuedr I 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 i certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt employ persona subject to workman's compensa- tion laws of California." The appicant mu call for all uir Mspecfl s. Complete drawing on reverse side. ) j Signed X Title: j �t''tGtp�iFC�l4GtSr [/s �� Date: 11 FOR DEPARTMENT USE ONLY Application Accepted by Date Area U',' 2 Area Pit or Grout Inspection by Date_ Final Inspection by-! ! 1 ` 'T 1~✓ Date Additional Comments: Applicant -" Return all copies to: San Joaquin County'Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 01$ox 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EH 3-24(REV. y /L 4.2 •r S.IBfH, 3/ I s 1