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�- -i APPLICATION FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESREC""41E �2I% ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 J U N Z 8 1991 (209) 468-3447 ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is hereby ttade,to Sen Joaquin County for a permit to construct and/or install the work herein described. This ' application is made in compliance with San Joaquin County Ordin �b9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ! !/ Job Address f`r�d a �_ _`-` ,,,,,,,,,,« C� City Lot Size/Acreage r Owner's Name _____ _ `^-� �tldress -�+'.�" �/b `-ar'ws-t 1d'-"� Phor� S Contractor, d�Address"R3 14 d C, 7`3A�cense No.��35"6-Z` Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑� DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION � SYSTEM REPAIR 3- -/ OTHER ❑ Monitoring Well C� DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PtTS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f-1 Industrial © Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing r f i U Do vatic/Private C1 Gravel Pack 0 Tracy Type of Casing Specifications V� R� r1100tiblic to Other ❑ Delta Depth of Grout Seal Type of Grout (11U CJ Irrigation -� Approx. Depth D Eastern f_Surieco Seal Installed by Q I Repair Work Done 0-- Type of Pump H,p�'kSurf State Work Done 9� Well Destruction ❑ Well Diameter Sealing Material & Depth J Depth Filler Material & Depth L� TYPE OF SEPTIC WORK; NEW"INSTALLATION n REPAIR/ADDITION Cf DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence^ Commercial— Other Number of living units: -Number of bedrooms Character of wit to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest; Wolf Foundation Property Line DISPOSAL PONDS 0 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 Horne 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 of subcontracting signature eaMifies 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 must call f r all required ' spechons. Complete drawing on reverse side. c Signed X Title- Date: F R D ARTNtENT USE ONLY Application Accepted byDate T Area Pit or Grout Inspection by Date Final Inspection by Date L Additional Comments: / C Applicant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r EH 13.24 tlttEV.1 i n 51 EH,4•?0 �� 1 k t'