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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 J U N 19 1992 ENVIRONMENTAL HEALTH PERMIT-EXPIRES Y FROM D T s PERMIT/SERVICES ��cl rc3oZ� � (Complete in Triplicate) Application is hereby made to 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 E (--)-6(0 _ eav=w 5-04 -- _ City Lot Size/Acreage 4—� 1 Owner's Name t�n S d `tAddress Nu Q J f Phone �on© 0,,Wa " �Jd5 �11_) nee fVo. 40� Phone rac or TYPE OF WELL/PUMP: . NEW WELL WELL REPLACEMENT .. DESTRUCTION 0 Out of Service Kell ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ `` Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �.. { INTENDED USt TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _. 0 Industrial ❑ Op"_Bottom _O Manteca Dia. of Well Excavation Dia. of Well Casing jomestic/Private 0 Gravel Pack ❑ Tracy 'type of Casing_ Specifications (1 Public 1-1 Other Fl Delta Depth of Grout Seal 7ype of Grout I I Irrigation —Approx. Dept I I astern ` ace Seal Installed by Repair Work Done L L] Type of Pump H.P, --- State Work Done Wall Destruction O Well Diameter l Sealing Material i Depth n Depth _ Z�a _- Filler Material i Depth Q` TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 2OO feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of toll to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ ' Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ � Method of Disposal i Distance to nea(ewl Well= Foundation Property Line 4 ~i LEACHING LINE ❑ No. &•Length of lines Total langthlsiza FILTER'BED l ❑ Dis anee to nearest: . ,Well ' Foundation Property Line SEEPAGE PITS X I Depth Size Number SUMPS Ll Distance to nearest' .. Well Foundation Property Line DISPOSAL PONDS ❑ - ! FI 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 l employ any person in such manner as to become subject to workman's compensation taws 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 laves of California." The applic ust call f aB required inspections._Complite drawing on-reverse side., Signed -Title: ' pate: FOR P MENT USE ONLY Application Accepted by Date ea Pit or Grout Inspection by Date Final Inspection by Dated 'r Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C K 1 RECEIVED BY ATE PERMIT NO. INFO • EH 1 -24 CRAY.fieis) !6?� FH 14.76 41/1