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L APPLICATION SAN JOAQUIN COUNTY PUBLIC H " ENVIRONMENTAL REAL T DI ON 445 N SAN JOAQUIN, PHONE f�' 6 — P O BOX 2009, STOCKTON,_�C 5201 lr PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate)' Application is hereby mede.to San Joaquin County for a permit co construct and/or Install the vork herein described- This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address CITY " �r lot Size/Acreage t C•' �a�C . 1 GCS S . ��! Owner's Name f Address_ _ Phoonn e Contractor I,Gx _ Address ! lem) License No._ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT :"l DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well E� DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I"l Industrial O Open Bottom ❑ Manteca Dia of Well Excavation. Dia. of Well Casing Fl DomesticlPfivale ❑ Gravel Pack ;-I Tracy Type of Casing_______ Specifications f') Public f-I Other (J Delta Depth of Grout Seal Type of Grout 11 Irftpatron --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump _ H.P. �_._____— State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Deplh Filler Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR!A DD17.IONT DESTRUCTION t I (No septic system permitted if public sewer is --�� available within 200 feet,) Inslaualion will serve: Residence✓ Commercial _ Gtlter 1 Number of living units: --�— Number of bedrooms - Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK 0 Type/Mfg �� i Capacity 9�A • No. Compartments z�- PKG. TREATMENT PLT_ ❑ Method of Disposal Distance to nearest: Well en /L Foundation 7 Property Line LEACHING LINE No. 8 Length of lines - Total lengthlsize FILTER BED Cl Distance to nearest: Well T Founaeuon _AJ,—k Property Line :If) , SEEPAGE PITSDepth a. f Site_ Number SUMPS 6-e Distance to nearest: Well !�'n fi h Foundation 1 � Property Lina .30 f It DISPOSAL PONDS ❑ I hereby certify that I neve prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rubs 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 fol'which this permit is issued, I shall flat 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, l shall employ persons subject to workman's compensa- tion laws of California." The applic t at call for eN used i spections. Complete drawing on reverse side. Signed X `{ C� Title_ c'd!/� ��' Date: ��- '-9.3 FOR DEPARTMENT USE ONLY p Application ccepted by Date 2 Area I �� ,, q Pit or Grout inspection by Date Final Inspection by Date is-s8-93 Additional Comments: Applicant - Return all copies to; San Joaquin County Public Health Services Rtivironslental Health Permit/Services :d 0 j'bi-76'7 445 N San Jos. Rox 2009, Stkn, CA 95201 {,!(,J INFO AMOUNT DUE AMOUNT REMITTED C KSTIRECEIVED BY DATE1 I PERMIT'NO EM 13.24 1N EY EM 14-A I f I ! _ �(� f !!