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r 1 • APPLICATION FOR PERMIT � D SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Q ENVIRONMENTAL HEALTH DIVISION n P O BOX 2009, STOCKTON, CA 95201 OCT 3 0 1992 �.J (209) 468-3447 p&RliIT MMIR,NO I YEAR FROM DATE ISSUED ENMRONMEMALHEAUH (Complete in Triplicate) PERMITISERVICES Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in cmwliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services, Job Address QA 1 Citye-e-a_Lot Size/Acreage owner's Name C131 L.-'^_ L 5-` WI 0IrP-4 � lbr'ss: 6�Y - Phone �z�7 Z - Contractor a C�.G��trlYlrl I Address F. M f �L License No 1 3.3L Phone =5-871 SL- TYPE OF WELL/PUMP NE ELL ❑ WELL REPLACEMENT OESTRUCTI �t of Service Well 0 C3PUMP INSTALLATION r- Monitoring Well DISTANCE TO NEAREST SEPTIC TANK EWEA LINES OI OSAL FLD PROP LINE FOUNDATION ER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA TNS n PVC F` 17 Industnsl ❑ Open Bottom Manteca Ora of Well Excavation Dim of Well Casing G �]+ U Domesticiprrvste %Gravel Pack 0 Tracy Type of Casing PV0-- SCh a +0 Specifications Cl Puolic 11 Other O Delta Depth of Grout Seal • Type of Grout q m -F, 'CLCl Irfluatron Approxi Depth ❑ Eastern SuAace Seal Installed by ... Repair Work Done G Type of Pump H P State Work Oona , Well Destruction O Well Diameter Sealing Material i Depth Depth Piller Material i Depth OF SEPTIC WORK NEW INSTALLATION 0 REPAIRIAOOITION Ll DESTRUCTION CI IN* septic system permitted of public sewer is evadable within 200 }eat I _ stallietion will Residence— Commercial— Other Numberr, of Irving units bet of bedrooms Character of god to ■ depth of 3 foot Iter table depth SEPTIC TANK ❑ Type/Mfg Capaci No. Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest WellFounda Property Lina LEACHING LINE 0 No 6 Length of TaIII tan i:As FILTER BED ❑ Oistsnce nearest Wail Foundation Property U SEEPAGE PITS Depth Sue Number SUMPS LI Distance to nearest Well Foundation Property Line DISPOS PONDS ❑ I hereby cavity that I have prepared this application and that the work .will be done in accordance with San Joaquin county ordinances, state Laws, and rules end 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 parrot is issued I shall not + employ any person in such manner as to become subject to workmen s compensation laws of California Contractor's hiring or sub-contracting signature eartifieg the following 'I canny that in he performance of the work for which this permit is issued,I shall employ parsons subject to workman s compensa- tion is of or La " The epplic st call-for I r ins jx o mplate drawing on reverse side _ Signed X Title Date, 4=4 FORDEPARTMENT USE ONLY Application Accepted byy t' U,`^"�`y - ., Date y� Area �+ Pit or at�l spection by Dais Final Inspection by Date � r Ilton O ret■ OC 1; 1 4mid Applicant - Rrei y a o; 3 AQVUIN CO BLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAH JOApU1N, P O BOX 2009, STOCXTON, CA 95201FEE w J 1J INFO AMOUNT DUE AMOUNT RE�MjTTTEO CASH RECEIVED BY DATE PERMIT NQ LTN a 7g l