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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMISNTAL HEALTH DIVISION PAYMENT 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 REC,E!VE0 PERMIT E%PIRES 1 YEAR FROM DATE ISSUEDNov 1992 (Complete in Triplicate) SRN JOAQUIN GO',NTY 4fi pLIBUC iH EAI-1 H JTE'-1 Application is hereby made to San-Joaquin County for a permit to construct and/or install the rrorlt(herein'fdesc�r�lbed�1 This J application is made is catillance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Name — Address1 tet - Phone 823---2da Tv Contractor, 6gE C Address 68A License No. f Q Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR )tg&*nt k4J,40THER ❑ 14onitoring Well n DISTANCE TO NEAREST:-SEPTIC.TANK_ .. .SEWER-LINES - ,DISPOSAL FLO. PROP. LINE_ _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial D Open Bottom © Manteca Die. of Well Excavation Dia. of Well Casing )t Domestic/Private ❑ Gravel Pack n Tracy Type of Casing— Specifications I'l Public Cl Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I (eastern Surface Seal Installed by Repair Work Done �/I, Type of Pump_,64rl i= H.P. ! State Work Don 7Ad Well Destruction ❑ Well Diameter Sealing Material i Depth r � � ` Depth filler Material i Depth ~ \ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIAOOIT15N I I DESTRUCTION I i fNo septic system permitted if public sewer is available within 204 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of-sol to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. b Length of lines Total length/size FILTER SED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS TCl_}Distance.to.nearest _Well -- Foundation' �Property-Lina- —� -, �... �..,.R DISPOSAL PONDS f ❑ 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 I 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, 1 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 mut call for all r trod inspections. Complete drawing on reverse side. k Signed Title: T1 6� _ Date: _o—`Yl� FO R A 4:PAR / Application Accepted by 4 Date �r res Pit or Grout Inspection by -Date Final Inspection f E Additional Comments: I 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 RECEIVED BY TE PERM17'NO. INFO _CAOA I . EM 13•t4 IIttV.i r n sr � r � EN tt-ffi 1