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APPLICATION FOR PERMIT -SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ppyMIf'UT ENVIRONMENTAL HEALTH-DIVISION R E C E IV F-0 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 JUN 0 1990 PFJWIT EXPIRES 1 YEAR FROM DATE IggiUED (Complete in Triplicate) KL _ trNiROp�N��MEN� C S�LTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work h�� .III scribedRVt . This f application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address z/ k-ee `4r � City ��r^ Lot Size/Acreage �Iy Owner's Name _5✓"eko- (_aG4 Address Aet'rtk_,2,o L,-i f_ Phone 15 65?k Pd go<"7U �dw Contractor (114", PaIII)IG Address Lr C-'01'k i CA g56�19 _T License No. 5 Phone - S TYPE OF WELL/ UMP, NEW WELL ❑ WELL REPLACEMENT C.3 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK _ &14' SEWER LINES _ r DISPOSAL FLD. Uk_ PROP. LINE-- FOUNDATION 3sZ-_q_0L_ AGRICULTURE WELL �_ OTHER WELL tPIT515UMPS �� b°'" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS L) Zu Industrial ❑ Open Bottom D Manteca'.' Dia. of Well Excavation Dia. of Well Casing [:] Domestic/Private KGravel Pack Ll Tracy Type of Casing 1/ 64A q6 ,,S!cciificarttiions. 42-OZO std f'1 Public El Other f-1 Delta`�� r Depth of Grout Seal.$-,- h Z-:066 iype*"o�t;rout��*v�'� I I Irrigation -VApprox. Depth- ( I Eastern Surface Sedl installed bye C6.- _ I Repair Work Done ❑ Type of Pumpf�4— H.P. �� __- State Work one T _ } wit Destruction, C3ter Well Diamei1lk Sealing Material 8 Depth w r /�A f ( it l A561kh-OoX Depth ',�_ Filler Material a Depth �Q TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I f DESTRUCTION i I INo septic system permitted if public sewer is available within 200 feet.) !' Installation will serve: Residence^ Commercial_ Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table deptU�l SEPTIC TANK. h ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal 1 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tota! lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number Q SUMPS CI Distance to nearest: Weil 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, 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 subcontracting 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 must call for all requir d inspections. Coll to rawjDg on reverse side.nAA / 1 Signed XhvA �`'s"�,_(/ Title: Tzt��{3C A� Date: �� J)r►r A T SE ONLY Application Accepted by Date tea Pit or Grout Inspection b Date -z U Final InspectionDateG � Additional Comments: r Applicant - Return all copies to: San Joaquin County Public Health [ Services, Environmental Health Permit/Services 4 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUEAMOUNT REMITTED CK RECEIVED BY DATE PERMI7'NO. EHAi�-2546 INFO CASH . EH IREV.tins) d i �