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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH.,SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. ,. PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 9520i PAYM- T R E C E:I Vl-p PERMIT EXPIRES 1 YEAR FROM -DA (Complete in Triplicate) DEC 12 1990 Application ll�reb�tttttato San Joaquin County for a permit to construct and/or install the work herr?in described. This application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the l�] t$Qno of San Joaquin county Public Health Services. f1L EA'LT PERMIT/SERVICES Job Address Ciry Lot Size/Acreage f Owner's Nam -cc -- Address 3 Phone i ContractorRIA Address,91k License No.�%e+_ Phone 23 TYPE OF WELL/PUMP: NEW WELL 21 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER 16 Monitoring well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 's INTENDED USE TYPE OF WELL° PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications !'1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Jd Type of Pump ll�_ _ __ H.P, State Work Done Well Destruction O Well Diameter Sealing Material & Depth AAL&fr- Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I° REPAIRIADDITiON I E DESTRUCTION i I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms ` -Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L-1 No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS - C1 Distance to nearest: Well;- — - Foundation - "Property Line DISPOSAL PONDS © r 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 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 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'shall employ persons subject to workman's compensa- tion laws of California." The applicant mus c ar all required inspections. Complete drawing an reverse side. l �j Signed X t i�1 Title: Vrd�f_ _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date rea / Pit or Grout Inspection by Date Final Inspection by Additional Comments: Applicant - Return all copies to: Sen Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 IEEE AMOUNT 2DUE AMOUNT REMITTED CK�({CA�}S7H�] RECEIVED BY / DATE C� PERM17'NO. . EH13-24(REV.Iins) /�e�V 5o'r 3, i / L �� I 7t�—,33� EH 14.26