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APPLICATION FOR PERMIT SAN ioOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON 200 AVE. , PHONE (2 A.2171 gvma T, P O BOR 2009, S'I'OCRTON, CA �''pO��QQ'1�C(( qv1.J �l NOISi::i,H•L'�Tyy3H'Iy.LNHWN08LVJ3 PERMIT EXPIRES 1 YEAR INIEFMTIIt. -I6cFWffiI�d_ (Complete In Triplicate) uNIIOJAIIIIayOfNVS Application is hereby made to San Joaquin County for a permit to construct 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 Z.`A J✓Z ♦'I.CSr �v'> .� v �4-. City �"�+- �.C1 Lot Size/Acreage Owner's Name x_6-4 4-1-0 Address TSS S:.lPhone 91-116_ • �2-Z�30 Contractor tAi,:.. tt E C N Address 4,04 '�Xa License No.Aix ��`: Phone - •'1" TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 3x Monitoring Well X DISTANCE TO NEAREST: SEPTIC TANK '�, I• SEWER LINES jLr p' DISPOSAL FLO, — PROP. LINE 5in- j- FOUNDATION i.r� AGRICULTURE WELL 3CL,_ OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 7 r• C-1Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation it Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f- 41fG FI Public (.Q Other 5il.Delta Depth of Grout Seal C. i Type of Grout N� it Z-11%" I I Irrigation � Approx. Depth I I Eastern Surface Seal Installed by zy.� 4L Yv Repair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction ❑ 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 public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of Will 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 PAYMENT LEACHING LINE ❑ No. i Length of linesTotal length/size EF�� FILTER BED D Distance to nearest: Well Foundation Property Line L JAN 2- 4 1.992 - SEEPAGE PITS I I Depth Size Number H •NT SUMPS LI Distance to nearest: Well Foundation Proper rXQUtn-1 4C , Y T E$ DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San,leaqum 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 sub-contracting signature certifies the following: "I cenity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion jaws of California." The applica m t call forySarse side. II requir inspections. Complete drawing on r Signed X 1 _ Title: Date: I F7 Q2-- FOR DEPARTMENT USE ONLY c�1� Application Accepted by � v Date �I}.•,�q��n9��- Areai� ` Pit or Grout Inspection bye`/j2�,/ Date � � �Z Final Inspection by /Y��f{ ' Date�2- Additional Comments: I�w f 4 ryw q J wtsk6 C2-2� ?-Z- ta5Neded GY-0 r tAW t 4,_5J&UJ LA, -g2 q0 5p2r/,,QQ Applicant - Return all copies to: San Joaquin County Public Health �) Services, Environmental Health Permit/Services 1601 E. Rezelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE A'MMOOOUUNNT RREE�)MITTED CA(�S/�H RECEIVED BY DATE 9 /JPERM//I��T-NO. En U3.IREV.trn si . VL `� ( � MM / 5/• / - 72-6 EH 14 26