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f APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 J A N 3 1995 P 0 BOX 388, STOCKTON, CA 95201-0388 P RMT MIRES 1 YEAR FROM DATE SSUEJNVIRONMENTAL HEALTH (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 compliance with San Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. y n Job Address �Q ---- �� •,tit= City .� ��C�Y}_ .Lot Size/Acreage 000] A-Z Owner's Name -1 C!`� �S +�-r' ` Address i r` Phone * ••�__�tt L LeiCJq q4I Contractor � 0''t ;Address ~' �T�Q '+C License No. Q Z Phone L�_fV- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT f' " r,�ESTRUCTION ❑ out of Service Well Cl L PUMP INSTALLATION L SYSTEM REPAI ❑ �OrT�HER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,J _ DISPOSAL FLO. � PROP. LINE / FOUNDATION t/ AGRICULTURE WELL OTHER WELL= PITS/SUMPS J_Tr t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W6,L'0 Vve.f{' �Auv'l If El Industrial '❑ Open Bottom _ ❑ Manteca Dia. of Well Excavation—_S_ Dia. of Well Casin CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ V Specifications I'1 Public I CI Other . n Delta Depth of Grout Seal '1 Type of Grouta}'CEr`'e�� 1.1 Irfioalion _Approx.,.Depth I I Eastern Surface Seal Installed by r' Repair Work Done L] r Type of Pump. H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth= w filler Material i Depth O TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet,) Installation will serve: Residence)T Commercial_ Other Number of living units: w Number of bedrooms #- Character of &oil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well Foundation Property Line (� LEACHING LINE Cl No. A Length of lines Total length/site FILTER BED ❑ • Distance to nearest: Well Founoation Property Line D I SEEPAGE PITS 11 Depth Sia Number r` R SUMPS Ll Distance to nearest: Well Foundation Property Line - - DISPOSAL PONDS ❑ I { 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 San Joaquin County Home owner or licensed agent's Signature-oertifies 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I&hall employ persons subject to workman's compensa- tion laws of California." The applie i mut ca for required inspections. Complete drawing on reverse side. - G Signed 4 M_ — �� l�4 e Title: L 1`-O?@� Date' # ..,_ FOR DEPARTMENT USE ONLY Application Accepted by DateArea Pit or Grout Inspection by Date Final Inspection by. - t1AA111k7s�w1s�1. Additional Corments: R - Applicant - Return all copies tof"' San Joaquin County Public Health Services ' Environmental Health Permit/Services - 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH I RECEIVED ItY DATE PERMIT N0. . EH1�3.24ir+Ev.riAat � lJ� '1 3q �• � I PD�J+'�L] a EH t •�e f/