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APPLICATION FOR PERMITE IV E u SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION S E P 1 8 1992 1601 E. HAZELTON AVE. , PHONE (209)46$--3420 P O BOX 2009, STOCKTON, CA 95201 M1IRON M rNTAL HEALTH j RES 1 YEAR FR M DATE PERMIT/SERVICES I (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ord once No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 110 `/s.G9�5j��'/=-',� �'7 '^1 Job Address �'� i City Lot Size/Acreage � Owner's Name ass IFO Phone � Contractor_ 'r � A Address m A No: Phone 5 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ r PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial C1 Open Bottkim ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1-1 Domestic/Private ❑ Gravel Pack _ L7 Tracy Type of Casing Specifications i'I Public fa Other l n Delta Depth of Grout Seal Type of Grout tair rrigation �.Approx.i Depth l I Eastern S e Seal installed by Work Done LJType of Pump# H.P. State Work Dane Welt Destruction ❑ Well Diameter seen n$ Material & Depth Depth f Piller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I lNo septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence— Commercial_ Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:*1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED CI Distance i nearest: Well Foundation Propefiy Line SEEPAGE PITS 11 Depth Sire Number SUMPS Cl Distance hoff nearest: Well Foundation Property Line DISPOSAL PONDS C3 .1 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 cenifies 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 mariner 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-tFifs'permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m t c II fo qu' spectio Co ate dr ing on r&a. + it Date: r— Signed 7 OR D T ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Dat+Z Additional Comments: Applicant — Return all copies to San Joaquin County Public Health Services, Environmental Health Permit/Services j 1601 E. Hazelton Ave., P 2009, Stockton, CA 95201 E A UNT DUE�.� AMOU T REMITTED CK RECEIVED RY TE PERMIT NO. IN 0 kt . EH 13-24IREV.iin5 EH 14.28 ..