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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 t4 0,V 2 3 1992 (209) 468-3447 SAN JOAQUIN COUNTY PUBLIC HEALTH SE?ViCF.S PERI[iT EXPLRES 1 YEAR PROM DATE ISSUED wVVIRONM�iV7ALHEi,,-IhplYl;roti (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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address � W t" 57— City Lot Size/Acreage Owner's Name +�-p��f�c7F+ ` s Phoma LZ _LZ Contract _ / Addres& �� LicenseC�'�r Phnne � TYPE OF WELL/PUMP'. NEW WELL ❑ WELL REPLACEMENT C:3 DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LY OTHER ❑ Monitoring Well Ll 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 rl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing G Doo tic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications 1G}'Pr�blic El Other ❑ Delta Depth of Grout Seal Type of Grout 0 Irrigation __� Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done rel Type of Pump H.P.' State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 7l DESTRUCTION 0 INo septic syslem permitted if public sewer is available within 200 toot.) Installation will serve: Residence^ Commircief Other Com' ! Numbii of'Wihp units` Number of bedrooms y a Character of soil to,a depth of 3 feat:, ater table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Gl Method of Disposal 4� 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 Sire Number _ SUMPS Cl Distance to nearest:' —Wein Foundation Property Line — 'r 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 cenifies 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 workmen'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 taws of California." The app=must al' gwred inspectin Complete drawing onit e side. Signed Title: .- Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: SAN JOAq IN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BO 009, STOCKTON, CA 95201 FEE INFO AMOUNT DME. l AMODU-NST REMiTTEO Gxp�^ RECEIVED BY DATE PEFIMIT'NO. . EH t3•Z4 I1tEV.iinsr V i/ J. EH 1{•26