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APPLICATION FOR PERMIT y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 j4,T2O_Z'7'fa€r7� P O BOX 2009, STOCKTON, CA 95201 APR 2 2 1993 e0XA_"P z-y S f2v3 PERMIT EMPIRES 1 Y]3_M FROM DATE ISSUED �If f � C�oZor4a in Triplicate) E'A" i`a�`�TM Imede to San Joaquin ountypermit to construct and/or install the work herein described. This a in Compliance with San Joaquin county Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. npA/ /'75--03 —_37_-+33 I; r! jl . Job Address SSE' M I�N arQs�pb—Dy Og 9 L� Lot 33ze/Acreage Owner's Name WA N LYaN Address _._ p?4c yu:> Phon ff)— 77 i Contractors �_-+ ress 2ZZc! 13 mV9.n r_ 51: License tiq,�Ti {�_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O01 Ser7tce Well tn ; PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 66f Q� r CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ 1"1 Public Cl Other fl Delta Depth of Grout Seal mut I I Irrigation —Approx. Depth i I Eastern Surface Semi installed by Bw / J Repair Work Dons U Type of Pump H.P, State Work Done W Weil Destruction ❑ Well Diameter Sealing Material & Depth 11�� P u Depth biller Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I 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 and 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 LINE Cl No. S Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Liner SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Linel w 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 Sen Joaquin County Home owner or licensed agent's signature oertifies 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 bacww 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 persons subject to workman's compensa- 3, P tion laws of California.,' The applicant Must call to required inspgctions. Complete drawing on reverse side. IL Signed Title: t Date: F D RTMENT USE ONLY Application Accepted by Date r:! ea Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: ,' Applicant -.Return all copies to: San Joaquin County Public Health Services " Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITT INFO ED CK RECEIVED 9Y DATE PERMiYND, �y CJL� . Err 14.25{REY.i/n a ]�- t�, 19F _ u �T EH t42a [J � _l ^.