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APPLICATION FOR PERMIT i SAN JOANQUIN COUNTY PUBIC HETHIRONMENTAL HEALTH DIVISIRVICES ON VE 1601 E. HAZELTON AVE. , PHONE (209)468-3420 AUG 1 1990 P O BOX 2009, STOCgTON, CA 95201 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DAIR ISgPED PERMIT/SERVICES (Complete in Triplicate) z Application Is hereby msde,to San Joaquin County for a permit to construct and/or install the work herein described. This application is grade in compliance with San Joaquin County Ordinance No. 5h9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Name Ok&Lu UA— Address Phone rD) Ia�� SI-3 t�10 n ctor Ad r License No. Phone TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION, SYSTEM REPAY 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 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing estic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications k I'] Public El Other � �(� Delta /,� r "Depth of Grout Seal f 1 Type of Grout i t I Irrigation _..Approx I as ern f k.Syttrtace Seal Installed by Repair Work Done ❑ Type of Pump P:--S12 —S, or one Well Destruction ❑ Well Diameter ealing Material & Depth Depth Filler Material & Depth (� f TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is —available within 200 feet.) + Installation will serve: Residence— Coimmercial_ Other Number of living units: Number of bedrooms \t J Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ,--❑- Type/Mfg,- Capacity - No:-Compartments "• � I PKG. TREATMENT PLT.❑ } ;Method of Disposal y Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/`size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line - _ ,•DISPOSAL PONDS 1—D I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laJan 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 appficarl,111Dftd all f r all ui d ins ctions. Complete drawing on re se side. Z, Sign X Titl Date: F DEPARTMENT USE ONLY Application Accepted by Dale r r p Area oC Pit or Grout Inspection by Date Final Inspection by Date/' e Additional Comments: 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 FEE INFO AMOUNT DUE AMOUNT REMITTED Ck CASH RECEIVED BY DATE PERMIT'NO, . EK 13.24 IREV,1/K5) Ul EH 14.26