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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION FpYMETl 445 N SAN JOAQUIN, PHONE (209)468-34WECEIVED P O BOX 2009, STOCKTON, CA 95201 CT 15 1992 PERMIT EXPIRES 1 YEAR FROM DATE ISSU �OAQU1t4(, 'yT (Complete in Triplicate) pUBLICHEALTHSERVICES (��nA�[N�17TpII HEALTH DIVISION Application Is hereby made to San Joaquin County for a Permit to construct and/or Srrs"CaW1'SrR herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 rand the Rules and Regulations of San Joaquin County(Public Health Services. /� APN z��`" �/o-3 L `q Q 4-, 911� /'Sl ) Cay�_ Lot Size/Acreage Job Address �w /// /`� � f 317-1 Owner's Name Jib Y2C'kGIf J4G Gn CC, Address ISR Spv�nkdf •F M4rJ'ac u.) Pryhone 1-�- Contractor ipyam�t+. 4-5.nX Address 37221 tlw,.q /Ifoa of License No. /" -7D Phone 3'�' �_� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES iDISPOSAL FLD. PROP. LINE y� FOUNDATION AGRICULTURE WELL S_��f OTHER WELL ! PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom Manteca Die. of Well Excavation 12 2 Dia. of Well Casing Cl Domestic/Private VIGravel Pack ❑ Tracy Type of Casing--_it • J?o Vic Specifications ('I Public 11 Other 71 Delta Depth of Grout Seal / Type of Grout 1=ere s7t'Lrcc� I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed hL rG+3'• Repair Work Done ❑ Type of Pump H.P. 1 State Work Done _ Well Destruction ❑ Well Diameter 1 .211 Sealing Material i Depth PY k q i� Deptn it�f Filler Material i Depth 4:;t gVel - 4 S' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITION I I DESTRUCTION I I INo seplie 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 soil 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 Lira LEACHING LINE ❑ No. d Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 Hone 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: "1 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 an�reverse side. ` Signal r_ Title: /"(G/Zr 7t.�a.enc �`?L7/Lseei- Date: 0 / OR DEPARTMENT USE ONLY Application Accepted by , LY �� Date �D Area Ph or Grout Inspection by Date Final Inspection by Date Additional Comnenta: _ Applicant - Return all copies to: San Joaquin County Public Health Services 2 1r � 0 S Environmental Health Permit/Seryl cee Jo 445 N San Joaquin, P O Box 2009, Stirs, CA 95201 INFO AMOUNT OVE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT'NO. . EM 1124(REV.I/x el EH la-am