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• APPLICATION FOR PERMIAD SAN J UIN COUNTY PUBLIC HEALTH SERVICES PAY MI TIRONMENTAL HEALTH DIVISION RtiCt(yg0ZELTON AVE. , PHONE (209)468-3420 ��i2'' OR 2009, STOCKTON, CA 95201 APR 2 5 1990 SAN JO RES YEAR FROM DATE ISSUED HEALT4i� • PUBLICHSERG IS in Triplicate) aaaJJJ Application is hereby dl�rflflRld�&€NrT��1�A�dt6V} �9 s 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. .1 Job Address L1�;��7 O lrr f/'1'? City k,.4,4— �4^ Lot Size/Acreage Owner's Name Address /UZ 1 f� `!✓Y Phone 11L Contractor j7j[7l�'/S' " A15zc , Address LZ?Z.S, 0,s� //J/ License No. Phone j4/r080,5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION - Out of Service Well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well f7 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications — ('I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction Ar Well Diameter Sealing Material L Depth 6 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will some: Residence_ Commercial_ Other /f{ Number of living units: _ Number of bedrooms Character of and to a depth of 3 feet: 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 Ll No. & Length of lines Total length/size ,L FILTER BED f-1 Distance to nearest: Well Foundation Property Line l SEEPAGE PITS It Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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 Sen 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, 1 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 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 applic all or all required inspections. Complete drawing on reverse side. ZZ Signed 6! Y-' �� Title: nUSE /S"d" Date: 9fl P MEY q tJ Application Accepted by Date 5-7Ef _ 2'n Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: �• Applicant - Return all copies to: San Joaquin County Public Health �'.yilfi✓!ju✓a Y/ ��ft,.,�.fli_ /��. -l-�f� r Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BV INFO DATEE [TPEFIMiT O.EH la@I IflEV.r/xsl .�EH'A 20 J V �