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APPLICATION FOR PERMIT LIM SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES" ENVIRONMENTAL HEALTH DIVISION APR 2 0 1992 P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 ENVIRONMENTAL HEALTH PERMIT EXPIRE_ I YEAR MR-DA,IE ISSUED (Complete in Triplicate) Application is hereby smde,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliancd vith San Joaquin County Ordinance No. 549 and .1662 and the Rules and Regulations of San Joaquin County Public Health Services. St k GDcla: Job Address L040 trot afi a/'rvtf fZosc'17E'5 $12 City L-Odc Lot Size/Acreage �e��n� / Owner's Name _- - _ 1 mis'/s Address 2ooa �rsf 1 G��-y l�aac� Phone Contractor k10-4 fa Drdb Address pn 13o4 k, U>�* Cl'3 License NoS1i 0 Phone-7b-7-� TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT C_l DESTRUCTION 0 Dut of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR L1 OTHER O Monitoring Well,,K DISTANCE TO NEAREST: SEPTIC TANK 75"0 *'t< SEWER LINES !T X611 DISPOSAL FLD. PROP. LINE _ FOUNDATION God AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom O Manteca Die. of Well'Excavation i-r-A Dia. of Well Casing P L) Domestiv Private XGravel Pack O Tracy Type of Casing Pyc Specifications schr /` ya M Public I:1 Other ❑ Delta Depth of Grout Seal --'1VzQ Type of Grout s e,+re r� slvrr-, G lrrioation Approx,�Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Wall Destruction O Well Diameter` `Q )n ch Sealing Material i Depth 1��n 4e_,-I- /4 s Depth 1 10 Filler Material & Depth s iygr.s r f4lr�'_ TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines _ _ - ;tk" Total length/sire �}} FILTER BED .4 n Distance to nearest: Wal! Fou dation Property Line C t C SEEPAGE PITS ( I Depth i' Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant 'ust co cal or all r u' ons. Complete drawing on r yerse side. `9 i Signed ! Title: t Date: FOR DEPARTMENT USE ONLY q Application Accepted by Date " i Area 11� Pit or Grout Inspection by D.antrerl —Final Inspection by..-_ _ Data! .. Additional Comments. 3 MV1 IAW T rv1 f Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 'Lq . ba HEALTH DIVISION PERMIT/SERVICES ST 445 N SAN JOAQUIN, p 0 SOX 2009, STUCKTON, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED K 0 CASH RECEIVED By DATE PERMIT�NO. �� -t. '` �� 5 S R2 q Iin5� 2-1az3 . EH 13-2t(REV. EH ta•2e