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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 ; PSR_ YIT E%PIRES 1_ YEAR E%LM DATE 000 (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I P/NE ST.1 AgS 'E 0 e$'• /705E S'r City L�D� Lot Size/Acreage Job Address Owner's Name PG&E Address POBOX 230S Phone u Contractor General Const. Address License No. Phone 1 TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT 10 DESTRUCTION ❑ out of Service Well ❑ OTHER ❑ Monitoring Well 0 PUMP INSTALLATION C3 SYSTEM REPAIR ❑ �4r 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 D Industrial I Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing — - CType of Casing Specifications l Domestic/ ❑ Graves Pack ❑ Tracy i 9 SaC�C MIX PPurb33lli�icii 1-1 Other Cl Delta Depth of Grout Seal g7 Type of Grout �hHUtlen —Approx. Depth I I Eastern Surface Seui Installed by Wel l Dona Repair Work Done U Type of Pump H.P. t Wor _ Sealing Material i Depth ��icre'�e Well Destruction ❑ Well Diameter oke Breeze Depth Filler Material i Depth F SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I iNo septic system permitted if public sews available within 200 feet.) Installation will se Residence_ Commercial Other Number of living units: umber of bedrooms Character of soil to a depth of 3 feet: or table depth t Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT.❑ Method of Disposal l Distance to nearest: Well anon Property Line LEACHING LINE ❑ No. 8 Length of tines engthlsize FILTER BED ❑ Distance to st: Well Foundation Pro Line SEEPAGE PITS Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line AL PONOS ❑ 1 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 applicant ust all for all r 'ad in ctions. Complete drawing on reverse side. Signed a Title: Engineer - Estimator Date: 4-20-90 FOR EPARTMENT USE ONLY Applicalion Accepted by Date � U Area 0 Pit or Grout Inspection by Date Final Inspection by2 _ Data t t(TP **ra ' T. cP Additional Comments: n Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton. CA 95201 CK a FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT NO. INFO qq Q EH,a4a