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k u, APPLICATION FOR PERMITtyy;�� sVED SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION N O V 16 1990 P O BOX 2009, STOCKTON, CA 95201NV ®NMENTAL HEALTH (209) 468--3447 PERM IT/SERVICES k=IT ESPLRES l_Y8AR f$Q9 RATE ISSUED (Complete in Triplicate) Application is hereby afade.to Sap Joaquin County for a-permit to construct and/or install the work herein described. This application is made in coWliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules.ewd Regulations of San R Joaquin County Public Health ervieeo. rO Lot Elise/Acre e Job Address �� ----- - City a6 Owner's Name'✓ LL� /X Address ��CJ � Phone Contraclo l� ._.A dress &hZ3Z_'ecense No--</-4/0"/409 Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT/0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIO_�� OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _____ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS --INTENDED-USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS �--- 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing meslic/Private 0 Gravel Pack n Tracy Type of Casing Specifications M Public 1.1 Other ❑ pelta Depth of Grout Seal Type of Grout Ci Irrigation —.Approx. Depth ❑ EasternSurface Seul Installed by Repair Work pone U Type of Pump H.P. r tats Well Destruction ❑ Well Diameter Sealing Material i'Depth Depth Piller Material i Depth . iN TYPE OF SEPTIC WORK; NEWINSTALLATION 0 REPAIR/ADDITION Ll DESTRUCTION M iNo septic system permitted if public sewer is availabIs within 200.1set.I Installation will serve: Residence.r.. Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ""-Watei tatiis tleptat SEPTIC TANK ❑ T yp./Mfg Capacity No. Compartments PKG, TREATMENT PLT. Gl �" -` Method of Disposal Distance to nearest: Well Foundation Property Line z LEACHING LINE ❑ No. A Length of lines Total leAgth/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll.' Distance to nearest: Wolf Foundation Property Line DISPOSAL PONDS ❑ wl hereby conify.thot-1-have prepared this application and that the w_prk will be done in_eccordance_with_San-Joaquin_county_ordimnces,:state-laws,-and, . rules and iegulibona o} the San Joain- quCounty �„ - Home owner or licensed agent's signature certifies the following; "I certify that in the periomarice of.i"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 of sub-contracting signature cenifies 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 towing on re se side. Sign Titlo: Date: F EPARTMENT USE ONO 1,e—& `fd � Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by,5z Date 3 Additional Comments: Applicant - Return all copies to. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445'N SAN JOAQUIN, P'O BOX 2008, STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CASH 8Y pATE PERM11'NO. Js- a f • EM'4'20jv2411tEV.f/MSI EH:�• / �(JJ