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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE41111 E(`;� E IV ED, ENVIRONMENTAL HEALTH DIVISION keft E., .. HAZELTON AVE. , PHONE (209)468-3420 J UL 2 7 1990 P 0 BOR 2009, STOCKTON, CA 95201 ENVEEtONMENTAL HEALTH EXPIRES 1 YEAR FROM DATE ISSUIM PERMIT /SERVICES (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in c`omrpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Jab Address ' v Lot Size/Acreage ` 96 -�3�� Owner's Name�,se��l' ��t�� Address�� ifJ_K �Gc��I"/�'�`UL.r�.� � i 740a for / drgss cense N0_4 _Phone r D TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATIOO< SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 ❑ Industrial ❑ Open Bottom F-1MantecaDia. of Well Excavation Dia. of Well Casing t eraesticlPrivate C7 Gravel Pack L1 Tracy Type of Casing Specifications I') Public fa Other fl Delta .Depth of Grout Seal Type of Grout I I Irrigation 1. .Approx. Dept I astern Surface Seal installed b Repair Work Done 0 Type of Pump H.P. tate ork one._ �` /t1 Well Destruction ❑ W�11 Diameter Sealing Material & Depth/1't-uiJ L�r Depth 14 -T Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION l I (No septic system permitted if public sewer is .I1. - available within 200 feet.) Installation will serve: Residence— Commercial— Other i Number of living units: -AL Number Af bedrooms. Character of soil to a depth)of 3 feet: ' Water liable depth SEPTIC TANK ❑ I Type/Mfg Capacity No. Compartments O PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl YVa. 8 L' ngth:of lines Total length/size FILTER BED ❑ :f Distance to nearest: Well "l "€ Foundation Property Lin �n SEEPAGE PITS1 1 Depth i Size Number ° O SUMPS Ll Distance to nearest: Well �-' Foundation --- ----Property-Line - DISPOSAL PONDS. _C1 i.- .J 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 sub-contracting signature certifies the following: "I certify that in theperformanceof the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." �� " ` •-`. # The applica t st call f r all q ired inspect ons. Complete drawing on re rse'sigF Sign - _ •i - - -Till - - - - - '-�-Date:/ �/_'� IQ FQIR.D EPA RTIMENT--USE;ONLY-\ Application Accepted by Date 77- 36 Area Pit or Grout Inspection by I� Date Final Inspection by t Data Additional Comments: I� 1 Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services Q 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. �... EN 13-24 TREY.tin5r I (`''�'yfi"��- EH 14-n 'fI 11