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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PARI 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201Ay PERMIT EXPIRES 1 YEAR FROM DATE ISSU Sq "A ' 3 1993 (Complete in Triplicate) FNVI BLrCH��rryCOUNTV Application is hereby made•to San Joaquin County for a permit to construct and/or install the tVME hereTH�S��ERV1C p 1 application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulation b145anThis Joaquin County Public Health Services. / Job Address J 00 14orNev City Lot Size/Acreage I IF 6W Owner's Name -MLiq Address �j � �,I °" � �7�J- �7.— Phone Contracto Addres,-R License Nor_ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION 0707t of Service well ❑ PUMP INSTALLATION� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �AGRICULTU.RE WELT.- 07HER-WELL ;P.47S4SUMPS__ - _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom E Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i'I Public 1-7 Other f-1 Delta Depth of Grout Seal Type of Grout Jrrigation Approx. Det I I Eastern Surf ee Seal Installed by ` { Repair Work Done L] Type of Pump t H.P. Q Stag Work Dana psi Well Destruction ❑ Well Diameter ` Sealing Mate ial i Depth Depth ) Filler Material i Depth � TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system (� permitted if public sewer is > available within 200 feet.) (1 Installation will serve: Residence— Commercial_ Other t✓ ; Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity— No. Compartments EKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C_] Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L) Distance to nearest: Well Foundation - -�'='=@#SPOS�kt=-PQNDS�:a❑- _--- "'�— ..A.�= '�-'-�'- �...�;.,,,.�:-,-Property Line 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 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 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California.,, The applicant st call for req fired inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date�- �� Area Z.° Pit or Grout inspection by Date .Final Inspection by Dots�3 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 REMITTED CK RECEIVED BY INFO CASH DATE ^ PERMIT•NO. EH 124 IIIEV.I/n 51 EH 1l-4-2e r� U �.y� �J� 1 41( � CJ r v / Qr- / �