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APPLICATION FOR PERMIT 11T�t� COUNTY PUBLIC HEALTH SERVICES E � �V RONMENTAL HEALTH DIVISION 3�2009, STOCKTON, CA 95201C E I V E: ,, 1992 (209) 468-3447SAN J Ni �g ;; 1992 FNVPi{Ci�}h�i;ftfT �fTr'', i�i 'v' Y trete in Triplicate} ENVIRONMENTAL 4ALTH Application is hereby made,to'8en Joaquin County for a permit to construct and/or install the P"J� VJ%S This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules as egu tions of San Joaquin County Public Health Services. Job Address a Lr71,0t �e_ _� ' -- _-- _ City Lot size/Acreage Owner's Na � r Address __ __ Phone Conlr res ' icense Ph6ner TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C) DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION [ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 ; DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES- DISPOSAL FLD. PROP. LINE FOUNDATION —AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA`CONSTRUCTION SPECIFICATIONS n Ind isl C1 Open Bottom; ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omesticlPrivate 0 Gravel Pack ❑ Tracy Type of Casing Specifications M Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout 0 Iniga ion Approx. Depth ❑ Eastern Surface Seal Installed by ype Repair Work Done & Tof Pump H.P. i= I State Work Done Well Destruction ❑ Weil Diameter Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 7-1 DESTRUCTION CI (No septic system permitted if public sewer is t_ available within 200 feet.) , ,*e}. Installation will serve: Residence_ Commercial Other R (� Number of living units: Number of bedrooms b Cha►scter of soil to a depth of 3 feet: Water table depth SEPTIC TANK. p Type/M10 Capacity No. Compartments PKG.,,TREATMENT-PLT, 0 Method of Disposal f .. Distance to nearest: Well Foundation Property Line J - LEACHING UNE 0 No. & Length of lines Tdfal-length/size FILTER BED n Distance to nearest: We" Foundation Property Line SEEPAGE PITS 11 Depth Size Number 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, 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 parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature eartifies the following: "I certify that in the performance of the work for which this permit is isiued, I shall employ persons subject to workman's compensa. tion laws of California." The applicant must II all required ins tions. Complete drawing on revirse side'. Signed X _ ;��_ Tice: ��_---`-'-� �' `�- Date: aOZFLDE�PAIRITMENT USE ONLYApplication Accepted by Date f '� Area - Pit or Grout Inspection by l — - T Date Final inspection by Data Additional Comments: Applictwt - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BO 009, STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT �REMITTED a CK 0 1 RECEIVED BY DATE PERMIT'NO, EN 9H t`.IREV�iixSs P