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APPLICATION 2 ' QCL3 SAN JOAQUIN COUNTY PUBLIC HEALTH IRIGES-I g? 445 ENVIRONMENTAL AN UIN, PHONE (209) ff4S9 Z P O BOX 2009, STOCKTON, CA 9AW?104 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate)'-� go i Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. 76 application is made in compliance with San Joaquin County Ordinance No. 519 and 1862 and the Rules and Regulations of San Joaquin county Public Health Services. jyy�• 4 3 7 has t Mf ✓�vt Ulm City fir` Lot Size/Acreage Job Address �7 1 Lflry -60311615�s Owner's Name U -'l F`c rvtt^•7, � Phone SCI cif 7—� /UUCP 1j� �ddress g zea /=ifsq tr d Sr c57 ('?,10Contractor R encl'IC (�- cTi. c C'V'J 751�1cense No Address . SS`/979 Phone 2 WREP WEL�/PUMP: NEW WELL ❑ ELL LACEMENT 71 DESTRUCTION ❑ Out of Service Well TYPE OF ❑ � n nq OTHER QQ Monitoring Well L] PUMP INSTALLATION ❑ SYSTEM REPAIR C1�'^., .l •I PY'� y DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications Cl Domestic/Private ❑ Gravel Pack LI Tracy of Casing__Tracy Depth of Grout Seal Type of Grout [1 Public A Other ADeha I I Irrigation L Approz. Depth I I Eastern Surface Seal installed y H P _ State Work Done _ . Repair Work Done ❑ Type of Pump Sealing Material i Depth Well Destruction [3Well Diameter Filler Material i Depth L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADOI710N DESTRUCTION I afvailablerc system wthin 200 feet.)ied it public sewer is Installation will serve: Residence _ Commercial_ Other Number of living units: _. Number of bedrooms Water table depth Character of wil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal ` PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line 3 o \ LEACHING LINE CI No. & Length of lines Total length/size Line FILTER BED ,.� (] Distance to nearest: Well FounitaLon I 1 Depth Size _ Number SEEPAGE PITS �1 SUMPS /f-/r1 LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ work will be dons in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the 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 issuedall no employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's ti a certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ per k tion laws of California." Pq° Y Theaapplic must call r all r quired inspections. Complete drawin0'J°/�averse1sicltjI„ • Title: s" ' ■'} - Date: Signed PAYMENT j R DEP RTMENT L i '.C� /l arts RECEIyg� Application Accepted by Final Inspection by `SEP 10 1993 _ Date Pit or Grout Inspection by Date SAN JOAQUIN COUNTY J Additional Comments: Appl^l,�pnt - Return all copies to: San Joaquin County Public Health ServiWIRONMENTAL HEALTH DIVISION I` \ Environmental Health Permit/Services �--• 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 Zev-� 'w J I FEEAMOUNTCK RECEIVED BV DATE PERMI7N0. INF,.On" a�t, �y9DUE A�JM�OJ^UJyNT REMITTED CA'S��H{t s . EN 131a(REV.1/.er •1= Y / — C� / Lam. /r(`^Y 1 14 25 //