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'. APPL I CATION FOR PERMIT <br /> SAN J UIN COUNTY PUBLIC HEALTH SERVICES <br /> S YM �IRONMENTAL HEALTH DIVISION <br /> �ZELTON AVE. , PHONE (209)468-3420 <br /> 0% 2009, STOCKTON, CA 95201 <br /> APR 2 5 1990 <br /> SAN JO RES 1 YEAR FROM DATE <br /> PUBLIC HEALTH SETTRI{.�� lete in Triplicate) <br /> Application is hereby >����N? �1Yf'�dtiYty+ter a permit to construct and/or install the work herein described. This <br /> application 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. / <br /> City �' 4 - Lot Size/Acreage ,lG �- <br /> Job Address <br /> Owner's Name /G Address ,U'2' r��iu f�7s Phone <br /> At <br /> � 3��'=z�g8� <br /> Contractor 6fS { A�Z�� Address � 2 S, �<�y n l�al License No. Phone <br /> ell 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'l Public 11 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth ( I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ 6 <br /> Well DestructionPrWell Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of Boil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mig Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 <br /> rules and regulations of the San Joaquin County <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California' i <br /> The applic or all required inspections. Complete drawing on reverse side. <br /> Signed/ �� Title: - <br /> d5 Date: 90 <br /> P MENT USE ONLY <br /> C <br /> Application Accepted by Dace S U <br /> Pit or Grout Inspection by <br /> Date Final Inspection by C Date V <br /> Additional Comments: <br /> Applicant – Return all copies to: San Joaquin County Public Health '✓ ` 1 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE #MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. <br /> INFO �i <br /> ♦ EH 13-24IREV.1/951 �� 1Z1s <br /> EH 44-26 v� <br />