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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> N![E1H <br /> ENVIRO TAL HEALTH DIVISION RECE - - <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 SEP 2 5 1992 i <br /> PERMIT E%PIRES 1 YEAR FROMDATE ISSUED�'NV`RONMENTAL HEALIH.^ - <br /> (Complete in Triplicate) PERMIT/SERVICES <br /> Application is hereby made to San.Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is 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 /> Job AddressP-tiG City Lot Size/Acreage <br /> Owner's Name-A 401 WdAL11Z Address Phone .. <br /> Contractor Address11a License No. "7b Phone <br /> TYPE OF WELL/PUMP: —^" ", NEW-WEtV EJ' WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Kell 0 <br /> PUMP INSTALLATION In SYSTEM REPAIR { OTHER ❑ Monitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK '` SEWER LINES iDkSPOSAL FLO. PROP. LINE <br /> FOUNDATION_- AGRICULTURE WELL .T OTHER WELL PITS/SUMPS a <br /> INTENDED USE TYPE OF WELL .0 PROBLEM AREA CONSTRUCTION'SPECIFICATIONS <br /> Cl Industrial 0 Open Bottom 0,Manteca Dia. of Well Excavation Dia. of Weil Casing <br /> Domestic/Private ❑ Gravel Pack L7'Tracy Type of Casing_ Specifications <br /> I Public --lel Ottrer C-1 Delta Depth of Grout Seal! Type of Grout i <br /> I I Irri alion Approx. Oe I 1 Eastern Surfs Seal Installed by <br /> -Repair Work Done 0 Type of Pump P d H.P. L ' Statq Work Done, <br /> Well Destruction ❑ Wall Diameter �{ '�. Sealing Material lei Depth <br /> Depth f NuFiller Material i Depth <br /> F <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I f"`REPAIR.lADDiTION 1-I—DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation wdl serve: Residence_ Commercial 'Other <br /> Number of living units: Number of bedrooms 7 <br /> Character of sod to a depth of 3 feet: I - Water table depth <br /> SEPTIC TANK: ❑ Typo/Mfg Capacity No. Compartments - <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> { <br /> LEACHING LINE 0 No. f{i Length of lines Total length/stze <br /> FILTER BED 0 Distance to nearest: Well Foundation { Property Line } <br /> I <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ l <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stata-iaws, and <br /> rules and regulations of the San Joaquin County <br /> Homs 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 /> cortkfles the follo ' : ',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 Is. , r <br /> The apptics t call for all requir inspection o ate drawing on reverse side. <br /> Signed Title: Date: ) <br /> F DEPARTME USE ONLY i 1 <br /> 1lpplieition-Xcespiad�6y Date r 2 Area 1 _.. 'I <br /> Pk or Grout Inspection by Date Finallnspection'by Date j .Z./ <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> lFEE� AMOUNT DUE AMO NT REMITTED K'H EIVE BY OA E PERMIT'NO. <br /> . EH 14-2 s <br /> fREV.rico K J <br /> P2 <br /> EH 11•m <br />