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APPLICATION FOR PERMIT do SAN ORQUIN COUNTY PUBLIC HEALTH ..:VICES ENVIRONMENTAL HEALTH DIVISION PAYMENT 445 N SAN JOAQUIN, PHONE (209)468-34WECEIVED P 0 BOX 2009, STOCKTON, CA 95201 CT 15 1992 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) JOAQUTHSE vCES pUBLIrt,,C,t��nHNI7TEpApLHEe�LTH DIVIS!DP! Application is hereby made.to San Joaquin County for a permit to construct and/or i4mwRQ�I"'V ;t L, rEAL described. This _gppllcation in wade in compliance vith San Josquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin county�Puublic Health Services. 4plV Ul< Z 4Tt� a/0—3 14 jM Job Address ` /O 1� !KI ) p� City / G,m�+ I Lot Size/Acreage Owner's Name S,c r�KG/f S4VG�- 4 Address I&M s��'-�*ds ,w ti��aJ.C, P�hhone Z-�3— Contractor Bh,A IV,'T>�f Address 3722/ !y,e Zy 1 too/PPR License No. r ,!! 76 Phone 77�" TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well s ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,r�� DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL te.7_EL OTHER WELL-9— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _<Industnal ❑ Open Bottom `Manteca Die. of Well Excavation Dia. of Well Casing q Cl Domestic/Privets 'Gravel Pack ❑ Tracy Type of Casing&iT . ram Pvc Specifications } I'1 Public ❑ Other (l Delta Depth of Grout Seal Type of Grout Ce—e_,d� I I Irrigation —.Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter /�) 2 a Sealing Material i Depth P m Depth u.7 y Tiller Material L Depth �e bq✓e/ G Sr TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION 11 (No seplic system permitted it public sewer is available within 200 feat.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of moll to•depth of 3 feet. Water table depth �. SEPTIC TANK- ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal On Distance to nearest: Well Foundation Property Line Q LEACHING LINE ❑ No. A Length of lines Total lengtri/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS - LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby canity 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 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- tion laws of California." The applicant mu call f r all requir ins Complete drawing on rreverse side. Title: � Zr ra .TSigned Date: / O DEPARTMENT USE ONLYApplication Accepted by Date /0 az Pit or Grout Inspection byAgOR Final Inspection by Olt d Date Gro Y Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services 2 Joaquin, O S Environmental Rea1Lb Permit/Services t/Seryl ccs �aN1l�m� 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIFEET'NO. . EM ,1.24 IREV.v n m, /yy EM 4.2e / 0