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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTHIO ICES 't � i ENVIRONMENTAL HEALTH DIVIS t 445 N SAN JOAQUIN, PHONE (209)468--3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services�rS 4 4 3 Gl, l70 5 !2-�E,e City L�f h2o�z _ tot size/Acreage f 1 �r_/L Job Address Owner's Name Ike Romeaa Address �6ame -- Phone9 Contractor Address License No.3 715 6 0 Phone 462-7676 WELL REPLACEMENT ❑ DESTRUCTIOAIc�1�E?ut of Service Well Cl TYPE OF WELL/PUMP. NEW WELL Monitoring Well ❑ PUMP INSTALLATION El SYSTEM REPAIR C1 OTHER ❑ 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 Cl Industrial ❑ Open Bottom E3Manteca Dia. of Well Excavation Dia. of Well Casing [.7 Domestic/Private ❑ Gravel Pack El Tracy Type of Casing_ Specifications I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation . Approx. Depth I I Eastern Surface Sed1 installed by Repair Work Done tJ Type of Pump — H.P. _ State Work Done _ Well Destruction Well Diameter6 n Sealing Material & Depth Sand Depth f:z 5_'~ Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I INo availabptic system m rented if public sewer is le Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 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 person in such as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: " certify that in e 1 rlormance of the work for which this pormit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant II o r i ins Complete drawing on reverse side. Signed X Title: zific pate: 1 9 Oct 92 FOR DEPARTMENT USE ONLY Application Accepted by r Date 7 Area Pis or Grout inspection by Date Final Inspection by Date% Q Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2049, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTE CK ECfEIVED BY DATE PERMIT NO. INFO + EH 1124 4REV.I/h 5r 1 (/ EH 14.26 1!/ &0