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APPLICATION FOR PERMIT PAYi 'ST SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED 1601 E ENVIRONMENTAL AZEON AVE. , ALTH DIVISION PHONE (209)468-3420 ,�'V D 3 1992 P O BOA 2009, STOCKTON, CA 95201 MIN JOAQUIN COUNTY PUBLIC HEALTI I SERMCES PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 rj vIRONMENTAI-HEAT,;cNiSION (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 Services. D Job Address 2 8 12.? . 7—t.!/e- /I/ IT ��'•_ _ _ City o&&d �G Lot Size/Acreage Owner's Name G l Address _el2p �wG �v�f'S N� Phone St3- r , Contractor S Address 21_�— L[/ /�License No. 3 hr �7� Phone TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 D Industrial, ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public CI Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal installed by Repair Work Done U Type of Pump .S. b H.P. /-I"-- State Work Done z Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAtRIADDITION l I DESTRUCTION l I lNo 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: 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 ❑ No. & Length of lines _ Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 subcontracting 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." The applicant st c I for all r wired ins tion Complete drawing on reverse side. Signed X Title: ��/`!�C AagEIPZ^..,_ Date: ,l� 2 „Z FO EPA E Us NLY Application Accepted by Date /r aZ ea Pit or Grout Inspection by Date Final Inspection Dste%,e� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FELEO A RUNT DUI AM LINT REMITTED CASH CEIVEp BY TE PERMIT PfO.�A I jjj JJJ . EM13.24(REV.iiwS IC L ' EK 1/-26 /