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APPLICATION FOR PERMIT '�'l / SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 y ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a 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 Servi 'c cees. /� !� 7/0- w F!yR � ryV r' Lot Size/Acre e �V �C Job Address �{ C,i�tyR Size/Acreage Owner's Name �P StJS S1�ti r a--- -._. Address -/" s Phone - O Coniractorr�StlT► t rS _ Address � d'� ! 7� License No.2?72Q5 Phone...2 I-V TYPE OF WELL/PUMP: NEW WELL1K WELL REPLACEMENT ❑ DESTRUCTION Out of Service well ❑ PUMP INSTALLATION, SYSTEM REPAIR ❑ OTHER C7 Monitoring Well L7 DISTANCE TO NEAREST; SEPTIC TANK /0 � _- SEWER LINES DISPOSAL FLp. 152 PROP. LINE _6�a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing $eDomestic/Private ->6 Gravel Pack ❑ Tracy Type of Casing z_< Specifications- r7` I"I Public r 1-1 Other 1 ./f7� Delta Depth of Grout Seal /40 Type of Grout Celsl4i-T �LL�-_ _«t+� i I I Irritation LA�-AidDepth I I Eastern Surface Seal Installed by �-dL�yk6 r� Repair Work Done 0 Type of Pum i p H.P. State Work Done Well Destruction k ❑ Well Diameter Sealing Material & Depth f Depth l Filler Material & Depth TYPE Of SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION f I DESTRUCTION I I lNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence I Commercial_.._ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet.. Water table depth SEPTIC TANK. k ❑ Type/Mfg Capacity No. Compartments { PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line J� LEACHING LINE) Ll No. & LenIgth of lines Tota! length/size � FILTER BED ` t 0 Distance to nearest: Well Foundation r� -Property-Line .5 � :*,,� 1 SEEPAGE PITS' ; 11 Depth Size Number I} SUMPS _�L-1-Distance-to nearest:--•- .Well Foundation Property Line DISPOSAL PONDS 1 ❑ f �. k s ."a• ^� ' -1-hereby-certify that-l.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, 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." �4 The applicant/must II for all rjired inspections. Complete drawing on_rever"se side. l r Signed X ! /i[w+T,.,.._. Title: Q"t� J t - ____ Date: A2-1-90 FOR DEPA'RTMENT_USE ONLY - t � , i Application Accepted by / ' Date�y� Areat� Pit o rout4Inspection by e Date/U' Y C� Final Inspection by Data =� Additl Comments: _ V J. �Z <7Ji�rzz� rLr. ur. -- -- _ Applicant - Return all lcopies to: San Joaquin County Public Health —?S,P e r Ccicl_ H Services, Environmental Health Peradt/Services l 1601 E. Hazelton Ave., P 0 Box 2069, Stocktoa, .CA -'95201 FEE AMOUNT DUE [ AMOUNT REMITTED INFO C RECEIVED BY` DATE PERMIT N0. + EM 13-24(REV,i/n sl {{ ` 1�/ ( 9 �0 31 EH 14.26 4 4- 1 1 S r O C) ]—