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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION VVVVv P 0 BOX 2009, STOCKTON, CA 95201 OCT 301992 C (209) 468-3447 P=1M EXPIRES 1 YEAR IPROM DAZE-1§2M ENVIRONMENTAL HEALTH (Complete in Triplicalte) PERMIT/SERVICES Application L hereby made to Sao Joaquin County for a permit to construct alnd/or Sne tell the work herein described. This application 1s made in c0mPliance with San Joaquin County Ordinance No. 549 and 1862 and the Aules and Regulations of San Joaquin County/ Public Health Services. 1 Job Address —11X153 Yt{�.�1Y1 de.1-�1 I T !�j,jI.r-. City 14-8--CO—Lot Size/Acreage M Owner's Name( �1 �P SY (1, (t fele �R�lBress Jc� ) Phone (20 / -Z ContractotS � k 1.h'1 1 Address Jr M C�� 5%-• I $la3(fl.- �JloS-87/ License No. Phone ) TYPE OF WELL/PUMP: NE ELL ❑ WELL REPLACEMENT If ,,�DESTRUCTION ❑ Out of Service Yell ❑ PUMP INSTALLATION ❑ P$TEF♦-RFpst} ,Wri— iGa.m�1 Monitoring Yell tu{ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES Oil OSAL FLD. PROP. LINE /'t FOUNDATION ER WELL ,PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEGIFICATI NS I`� ❑ Industrial ❑ Open Bottom Manteca Die. of Well Excaystion'E Dia. of Well Casing 2PV U Domestic/Private 913favel Pack ❑ Tracy Type of Casing DVA 44) Specifications 13 Public 1-1 Other ❑ Delta Depth of Grout Seal I Type of Grout nee t? }� ❑ Irrigation �Approx. Depth ❑ Eastern Surface Soul Installed b 7P M1 r-utyY1 Repair Work Done 0 T `/ YPe of Pump H.P. Stats Work Dona— Well Destruction ❑ Wall Diameter sealing Material a Depth ii Depth Piller Material i Depth II TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADOITION CI DESTAUCTION ❑ INo septic system permitted it public sewer is !I available within 200 feet.) Installation will s • Residence _ Commercial_ Other i Number of living units: — bar of bedroomsT� Character of soil to a depth of 3 fast: �: star table depth 1 SEPTIC TANK ❑ Type/Mfg - Capaci No. Compartment Y PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Found- I Property Line LEACHING LINE ❑ No. 6 Length of Toial 106CIT0,41ze FILTER BED ❑ Distance nearest: Well Foundation Property LI Q � SEEPAGE PITSDepth Size Number IS SUMPS LI Distance to nearest: Well Foundation I�� Property Line DISPOS PONDS ❑ 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 rues 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: "1 certify that i he performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• tion laws of r; The app)' "Let calYfor 1 r mspe. mplete drawing oCn revers_s side. / ��. Signed Title: �Pht� C1.II 5 / Date: I FOR DEPARTMENT USE ONLY I� ' I Application Accepted byJD&I,2-11- 3 Pit or G1a01 speetion by &�eWW-YPBJ+�—Dnew �g�� tl,..i i,.......: Q- - Final ..._„_ction by L• Additionw, t41eYmc i� Applicant - ReZw aLi coy a o: g AQUI LIZ N COWV� HLIC HEALTH 9ERVICESf ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES ��.f•l'1P1 ' 445 N SAN JOAQUIN, P O BOX 2009, STOCKTOH, CA 99201 /Vv 'I IFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED�BY DATE PEAMIt'NO. EM 11 .70Iaev.11.51 IN:a•a! I