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f APPLICATION FOR PERMIT_ Y;0JyTV SAN JOAQUIN COUNTY PUBLIC HEATT SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 MAY 3 1 1995 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL (Complete in Triplicate) PERMIT/SERVICE 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 cee>pliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sam Joaquin County Public Health Services. Job Address Citysk-4k!V Lot Size/Acreage 3%'x 176' Owner's Name '"(.ole F41 i" [ AddLgss © f Phn-(510)(13_271 Contractor4WJ1 r"Address Stbcense No. t12-� � e `9712- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 121' Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES > �511Ft, DISPOSAL FLD. i PROP. FOUNDATION t AGRICULTURE WELL — OTHER WELL—Ig-76L PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of WeN Excavation_ S Dia. of Well Casing EI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications S'1 PubVic F1 Other �l�vep n Delta Depth of Grout Seal 0 Type of Grou Cr2 e at I I irrigation Approx. DhJ 1 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State ork Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Piller Material i Depth TYPE OF EPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installatio .will Residence Commercial— Other Num'bar of living units: Number of bedrooms Character of soll to a depth of 3 -7f—water able depth SEPTIC TANK Type/Mfg �ity- No. Compartments PKG. TREATMENT PLT.❑ + r {�� Method of Disposal Distance to nose t' 'WelF Foundation Property Line LEACHING LINE0 ,Leth of lines `� Total length/size FILTER BED '�!)Sistafice to nearest: Well Founds and t Property Line 5 A TS I I Depth Size Number `� SUMPS Ll Distance to nearest: Well Foundation Property L ni i� DISPOSAL 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 rules and regulatk m 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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting 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." Thea scant at call fo equ' inspections. Complete drawing on reverse side. Spn� Title: Date: R DEPAR .M NT USE ONLY ] -- Application Accepted by `� Date Area YI Pit or Grout Inspection bydate I a I j 4 �^ •„,.,Q ,`Final I.n�s-pection by Date Additional Comments: l ` � �� CJ��/w�/u-� 4 �S CO Applicant - Return all copies to: San Joaquin County Public Health Services (q Environmental Health Permit/Services [ � 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 l FEE AMOUNT DUE AMOUNT REMITTED CK RECEIyED BY DATEJ PERMIT NO. INFO CASH . EN 14-28 IIItY.I/n sl .00 r V V !`i � I l- r y �1 t .� EH lt•2a g lJ