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APPLICATION FOR PERMIT I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 It �7T Q 20-1000— 01 (209) 468-3447 Z Y (Complete in Triplicate) i Application is hereby made,to Sas 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address a`� 1 �' �— tr GJWW= U _ City Q Lot size/Acreage Owner's Name u Address N Phone 923" _5: I � ' Contracto s E nse No. 226 Phone `� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT' n- DESTRUCTION � to 1"g urt"�_ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER OiSPOSAL FLO. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ---�— PR41F 1 INF FOUNDATION AGRICULTURE WELL OTHER WELLJL1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation rlyn nr Wn�l ,,,,1 C�Asirfa LJ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing c ,erre _ ►cc M Public I'll Other ❑ Delta Depth of Grout Seal aype"ofrir�ut 0Irripauon Approx. Depth ❑ Eastern Surface Sedl Installed by 1(tel Repair Work Done L7 Type of Pump H.P. State Work Done_ Wall Destruction ❑ Well Diameter Sealing Materiel F Depth �N[�n( Filler Material i Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION 0 iNo septic system permitted if public sewer is available within 200 feetCA Installation will serve:•• Residence..r Commercial__-_ Other 0 Number of living units: Number of bedrooms Character of soil to a depth of 3 tees: Water table depth r SEPTIC TANK. ❑ Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT. Ci Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ll Distance to nearest Well Foundation Property Line DISPOSAL PONDS Cl I hereby certify that I have prepared this application and that the work will be dons in accordance with San Joaquin county ordinances. slate 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, f shall not i employ any person in such manner as to become subject to workmen'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 m 11 for all requ inspections. Complete drawing on reverse side. lf�s�sr -11-91 Signed Title: E�6 0Date: F OR EPARTMENT USE ONLY /y Application Accepted by Date - Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: -T411 , Applicant - Return all copies to'. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j Ltp ♦� t ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. INFO (� . EN 13.24 INEv.l i n 6) 1� 7 Mk ,1� L{ l 1 J6[ArJL Eli 14.20 VV L y