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APPLICATION FOR PERMIT U� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION J P O BOX 2009, STOCKTON, CA 95201ry (209) 468-3447 PAMIT EXPIRES 1 YEAR PROM DATE IS�BT2. ',J 1�`92 (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vor&''he tfh de¢0VL(b1_6*. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and RegtiiatlbjSi[,p :San J Joaquin County Public Health Services. r Job Address ..r*;�- —�a? -- Q�y�---- City mfr -- Lot Size/Acreage Owner's Nsmen:Ap. Address In) A4 V4AZ L'� one ContraciT�l��t�� %�. ,�^� Addres 4— �AMe No ra L� Phone '��l TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR &7--' OTHER O Monitoring Well [7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing U Do tic/Private Cl Gravel Pack n Tracy Type of Casing Specifications =blit Cl Other O Delta Depth of Grout Seat Type of Grout M Irrioation �' Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done a- Type of Pump H.P. _ State Work Done 94 A.. Well Destruction O Well Diameter Sealing Material 4 Depth Q Depth Filler Material 4 Depth 90 TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION CI DESTRUCTION CI (No 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's depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED 1-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that 1 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 cartify 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m r all required in)pq ions. Complete drawing o I reverse side. p Signed Title: �� Date: m a FOR DEPARTMENT USE ONLY pt Application Accepted by a Date l� es Pit or Grout Inspection by Date Final Inspection by ater Additional Comments: — Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O 009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17 NO. INFO }� ,�1 �^ . EH 1 .24 InEV.I/w s) M � V�/ �7-Cr� EH Uda