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APPLICATION FOR PERMIT SAN JOAQU IN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 N O V 161990 PERMIT RES 1 YEAR FROM DATE ED t� (Complete in Triplicate) _EWIRONAMAENT.AL WEALTH Application is hereby made,to San Joaquin County for a permit to construct and/or install the wor�kE'Eereli�We>go�kid. 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. 3 /�_�9 q , / rLoaA-OJ L�CL� i �� rTC�I.`J�Y1 ' ttS� City ) Lot Size/Acreage 154 A�.PCC. Job Address -- JJ -(- ga / j Owner's Name d l()elf GT .L�/�1��' Address T•0•ZOX 633tl 1 tY Llnn Phone ZSZsE Myr Ht, Sk C51 (arm, Contractor�ecT�_ Address �7t Ockr Vn License No SJ 7—z,&3 Phone /,3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION A Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 7r0 SEWER LINES —7�— DISPOSAL FLD2 PROP. LINE-750 HUJ- FOUNDATION AGRICULTURE WELL OTHER WELL_. PITS/SUMPS� —� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public 1-.1 Other n Delta Depth of Grout Seal Type of Grout � (� I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction X_ Well Diameter _q rt p Sealing Material & Depth Depth 14W4=401Ke tI'/ Fil pr Material & Dept bO e�fJ� v; TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I INo 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 soil 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 tQ LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I� SEEPAGE PITS I I Depth Size Number SUMPS Ll 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, an r rules and regulations of the San Joaquin County 1 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 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 t 11 for all requi spections. Complet drawing on rrev�rs i Signed X Title: -�-�f Date: / ,/ ! FOR DEPARTMEN USE ONLY Application Accepted by DateArea Pit or Grout Inspection by Date Final Inspection by Date la hho Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT y Dt1E—` AMOUpNT�jREMITT�ED CK RECEIVED BY DATE PERMIT''}N�O + EH 13.241REV.tixsl (� a5_0 `� q� EH 14'n