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APPLICATION FOR PERMIT I -� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �, a < ` ' P 0 BOX 2009, STOCgTON, CA 95201 � r I - t (209) ' 468-3447 � ti R J U H 1 2 1991 j (Complete in Triplicate) ENVIRONMENTAL H ATH Application"ie hereby made to San Joaquin County for a permit to conatruct and/or install the vorkRe ,i"�g�s f jbed, _This application is made in coa�liance,�vith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations"of`Sin Joaquin County Public Health Services. _! , Job Address - ��! � I in�P e `r�'� City Lot Size/Acreage Owner's Narhe �� _ Address Phone Contractor IvIn Address t�A ' License No. 61 Phone 3 TYPE OF WELL/PUMP: NEW WELL,❑ WELL REPLACEMENT ❑ DESTRUCTION L1 Out of Service Well {❑ PUMP INSTALLATION ❑ SYSTEM REPAIR f]' OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINT= FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial ! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Die. of Well Casing .tom Domestic/Private O'Gravel Pack- ❑ Tracy Type of Casing Specifications - ❑ Public I'1 Other 3 ❑ Delta Depth of Grout Seal Type of Grout SCJ-Irri ation A -"– --,-..– '" '— U pprox, pepthW#C]Eastern 5u�lace Seul Installed by Repair Work Done 0 Type of Pump4� H,P. — � lam State Work Done Well Destruction D Well Diameter . `f Sealing Material & Depth ' Depth ` Filler Material i Depth TYPE OF SEPTIC WORK: .NEW INSTALLATION❑ REPAIRJADOITION 0 DESTRUCTION G (No septic system permitted it public sewer is r I available within 200 feet.) Installation will serve; Residence_.._,i Commercial— Other, 4 Number of living units: Number of bedrooms `* Character of soil to a depth of 3 feet:' Water table depth r SEPTIC TANK. ❑ Type/Mfg r y CapacityNo. Compartments PKREATMENT PLT. 0 d Method of Disposal Distance to nearest: Well '�� Foundation Property Line 4LEACHING LINE C1 No. & Length of lines Total length/size I FILTER BED 11 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 11 Depth Sire" _"Number SUMPS LI Distance to nearest: Well Foundation Pro ` N- ''DISPOSAL PON05" r`r ❑=" �,.c, �- A •�� .. - _ �.,, - Li.,w.� 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 I " 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, t shall not employ any person in such manner as ta'hecome subject to workman's cornpansaiion laws T—Celifornia;" Contractor's hiring or sub contracting signature certifier the foil inp; "I certify that in the performance of the work for which this permit is issued, Il ahu smpla�persans subject to workman's compensa- tion laws of lif rrila." . The apple' s1 call for all requir ' spection omptate drawing-on reverse side. / f Signedif f Title D$'ta" L- 7-11 1 Vu U-DEPARTMENT USE ONLY '- Date _ �} Application Accepted by --� Da f `� Area t (� Pit or Grout inspection by i a e Final;inspection by i s - Additlona! Comments: AppllcantF`Return-all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES e '—ENVI'HOHNENTA'LHEALTH-DINI-8ION-PERMIT/SERGICE9 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 85201 yam► t / f FEE" AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PrcRrrllT'NO. v { INFD;: GASH . EH A2�iREV.t in Si ��- EH >a t+iri i _ p