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APPLICATION FOR,PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RECEIVED 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 N O V 0 9 1992 SAN JOAQUIN COUNTY PER T EXPIRES 1 YEAR FROM DATE ISSUM PUBLIG FirALTH SERVICES (Complete in Triplicate) ENVIRONMENTAL NEA,0HDIVISION! Application is hereby aade,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 Ordinance No. 51+9 and 1862 and. the Rules and Regulations of San Joaquin County Public Health Services. ` Job Address City 7-rCk y Lot Size/Acreage b•2� sow �.eCA P4-c- Ir�fts .CoAddress 0Ae I`LI Le; Q�Z� so� -A-gc� cPhone Owner's Name (4 IS 541 - 2E�T3 1� '5PEt--r�-IArn . - els S je. Myr+ s+. Contractor ExQl.o(ZA-`Ia�l ,.t_>rL. Address 541-k!-o CA 9520E License No. G1 �$ Phone{��`r 465-8 12 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ,4 Out Monitoring Well ice Well ❑ PUMP INSTALLATION ❑.f" t_ __. .�SYSTEM REPAIR © . T T OTHER L7 _ "". -.�--,� .�t-.��-�� .N•1�. SEWER LINES �i�'..� DkSPOSAL FLD. l4" PROP. ~' 7.DISTANCE TO NEAREST: SEPTIC TANK �►� FOUNDATION f AGRICULTURE-WELL I4A OTHER WELLS 7000 -PITS,ISUMPS, - M INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing L7 Industrie) O Open Bottom ❑ Manteca Dia. of Well Excavatiori'� -- g 17.1 Domestic/Private Cl Gravel f eek Tracy Type of Casing_ Specifications'� - ; 11 Public K Other n Delta Depth of Grout Seal Type o1 Grout l I i IrriLgation Approx. Depth I I Eastern Surface Seal Installed by V^ Repair Work Done U Type of Pump NA H.P. State or Do , 1 Well Destruction Wall Diameter" z 11 Sealing Material i Depth Depth Piller Maiiria.l i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION Ill DESTRUCTION l 1 (No septic system permitted it public sewer is 1 available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg `' Capacity No. Compartments- PKG. TREATMENT PLT.❑ t Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of linea Total length/size' ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITSr..FounI Depth I Dh Size Number . _. - .. _ . _ — - ., _- . ... _dation„ .-- Property_ Line ' �...Ll Distance to nrest: Well ea = DISPOtAVPONDS'• "D 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 rhe) 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 shad 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 canify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws o1 California.., The app)' t mus ll for all required inspections. Complete drawing on reverse side.,/ > S" ned Title: !ra,14 o f Date: 1 r - 7-5,z 4 _ FOR DEPARTMENT USE ONLY �� !/ G� Application Accepted byFA� Date i 1 Area Z*Z-F Pk or Grout Inspection byinal Inspection by Date �' Z Additional Comments: r Applicant - Return all copies to: San Joaquin Count Public Health Services �� Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE I AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO EH 13.34[REV.II%51 U `C EH 14.M r —