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91-15 APPLICATION FOR PERMIT 16--fol CILAy + SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i /0/ ' 113 -SA-b ENVIRONMENTAL HEALTH DIVISION /3o CI.A-� 445 N SAN JOAQUIN, PHONE (209)468-3420 �� P O BOX 20091 STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in' Triplicate) Application is hereby made to Ban 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address w City Lot Size/Acreage �30J{[� 9 10-1 Owner's Name k Address -7a) Phone Contractor -�kvuf-ucLiqAddress �5_A14.AA16 0 POdLicense No. Phone TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service hell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK ZJ= SEWER LINES - DISPOSAL FLO. .PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLS PITS/SUMPS L �O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �f C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack Tracy Type of Casing_ 1 Specificationss AU:2 ('1 Public 1"1 Other n Delta Depth of Grout Seal jaA. Type Grout AM VM J I 1 Irrigation Approx. Depth "1 I Eastern 'Surface Seal Installed by - Repair Work Done U Type of Pump H.P. State Work Done Wall Destruction ❑ Well Diameter Sealing Material A Depth ro ¢L wE Depth Filler Material A Depth # TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 1No septic system permitted if public sewer is available within 200 feet.) I installation will terve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soq to a depth of 3 feet: Water table depth 1 SEPTIC TANK . ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Cl Method of Disposal Distance to nearest: Well Foundation • Property Line ru. LEACHING LINE ❑ No. 5 Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Lt 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 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 appy nt st call for all requir inspections. Complete drawing7,rn reverse e. Slgrled Title. Date: 7 A3 FOR DEP TMENT USE ONLY Application Accepted by Date Z Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMITNO. ' IINFO ,A CASH . EH 13-21[REV.1)R 5) r ' a It p�V }� 6� nA_ Vim -� �� 7 EH 11-20 «JJ J