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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 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 r application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health services. Job Address (W-)41 6;-K T � ' City Lot Size/Acreage Owner's Name D Li 1 S n/A '"�4Address 1�l E Phone 23V Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D Monitoring Well DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O n Industrial ❑ Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing ' Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth t I Eastern Surface Seat Installed by Repair Work Done 0 Type of Pump H.P. State Work Done)C _ i Well Destruction [ Well Diameter ` Sealing Material & Depth AG,�&o5_.� ,-J17Lr- &0Y1-0-t 7-0 `]tP I Depth 2-�O rL'a Filler Material & Depth TYPE OF SEPTIC: WORK: NEW INSTALLATION I i-,,REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is '* a available within 200 feet) ' Installation will serve: Residence— Commercial— Other"Km" Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth j SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal j Distance to nearest: Well Foundation Property Line. I LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED El Distance to nearest; Well Foundation Property Line �4 i SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well —Foundation- Property Line DISPOSAL PONDS Cl 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 manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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 applicarytpttust call for all required inspections. Complete drawing on reverse side. _l1 t r Signed Tide:tl Date: IF4 L-1 OR DEPARTMENT USE ONLY Application Accepted by Date-4/0/90/, AYea e--46t-A6Srg yEa Pit or Grout Inspection by Date Final Inspection by rrKc:,r 0 14a Additional Comments: Applicant - Return alt copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 PER— INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. + EN 13.24 11IEV.v w 51 YJ�_ C7L� - Em 14.26 ��-.. _ '300 2-