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4. "-� APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PA ENVIRONMENTAL HEALTH DIVISION ��" P O BOX 2009, STOCKTON, CA 95201 S �� (209) 468-344'7 091992 SANJ: IT EXPIRES I YEAR ?ROM DAI�s ISSUED' :��fC0'�4�rIrU�0uNITY r1, N At rl r (Complete in Triplicate) '!,l�f ''�^ S`' .5 ��r Application is hereby made.to San Joaquin County for a permit to construct and/or install the work ryhereinzaies!�)I ',),This application is,made in coupliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County rPublic Health Services. Job Address Lot Size/Acreage Owner's Name gd.2 Address ___ ______ --- Phone Contract ddre *V6844- 3`''tLicense r 3 l 2 Phon � TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well 0 PUMP_,INSTALLATION © - SYSTEM REPAIR YY-' OTHER ❑ Monitoring well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION " AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11Indu nal 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia, of Well Casing Momestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications M Public 1'1 Other 0 Delta a Depth of Grout Seal Type of Grout r-I Irrigation _ Approx, Depth ❑ Eastern f urface Seal installed by Repair Work Done Type of Pump �/ � H.P. State Work Done Well Destruction O Well Diameter. Sealing Material ti Depth Y Depth Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION L) REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted it public sewer is t available within 200 feet.) Installation will serve: Residence Commercial— Other r Number of living units Number of bedrooms A Character of toil to a depth of 3 fear. Water table depth SEPTIC TANK O Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT.0 �..� Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: WellFoundation — - Property Line DISPOSAL PONDS 0 ., 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 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, t shall employ persons subject to workman's compensa- tion laws of California." The applicant must cal wired inspection_. Complete drawing on rove side, Signed Title: Dale: Y/ �. FOR DEPARTMENT USE ONLY Application Accepted by Date /O � Area Pit or Grout Inspection by Date Final inspection by' n �- Date 10 �z 92 i Additional Comments: Applicant - Return all copies to. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN.JOAQUIN, P O SOX 2008, STOCKTON, CA 85201FEE r INFO IA`MOUNT DUE AMOUNT REM yITTED CK RECEIVED BY DATE PERMIT No -f . EK 13•24 IREV.rinSr `f� UV 3I i['4 D