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, APP;ICAT�ON SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISIONRE r 445 N SAN JOAQUIN, PHONE (209).468-3420 t]I P O BOX 2009, STOCKTON, CA 95201 SEP 6 1991 ENVIRONMENT , PERMIT EXPIRES 1 YEAR FROM DATE ISSUID � ALHEAf7h (Complete in Triplicate) MIT/SERVICES 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 Ordinance Ro. 549-and 1862 and the Rules and Regulations of San I Joaquin County Public Health S w1ces. Job Address ity Lot Size/Acreage wner's Nam ddress Phone r ceAS, No. Phoneo C rII TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ 1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well. ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS d INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ I ustrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing._ Specifications I'I Public I-1 Other fl Delta Depth of Grout Seal Type of Grout 11 Irrigation __ Approx, Depth II a am Surface Seal Installed by JJ Repair Work Done 0 Type of Pump . H `- State Work Don , Well Destruction ElWell Diameter l/f _ +waling Material b Aepth Depth Zj:27' Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I 1 INo'septic system permitted if ptiblic sewer is F available within 200 feet.) —installation will serve: --Residence.�.:-Commercial_""Other Number of living units: Number of bedrooms1 ' -_'' a Character of soil to a depth of 3 feet: `�f _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ "Method of Disposal Distance to nearest: Well Foundation ; Properly Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line S \_A4 "4 ¢, SEEPAGE PITS 11 Depth Size SUMPS LI Distance to nearest: Well Foundation Property Line 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, stale laws, and rules and regulations of the San Joaquin County CCC Home owner or licensed agent's signature cenifies the following: "I certify that in the,perfprm_ancs of the work for which this permit is issued, I shall not employ any person in such[Wanner as to become subject to workman's compensatioh caws of,Californl Contractors hiring or sub-contracting signature li certifies the following: "I certify that in the performance of the work for which this permit is.itiaued, I shall employ persons subject to workman's compensa tion laws of California." The applic t st cal f r uired inspections. Complete drawing on rev -si ign Title Date: /6) FOR PARTMENT USE ONLYqn- �r l Application Accepted by Date r A- Area, Pit or Grout Inspection by Date Final Inspection by ate#1* Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit:/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE KJ AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PE ET'NO. . EM13-241REV.1/NSIt� e, ,l _M2 q , J�L3 i. E„1420