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F q F APPLICATION FOR PERMIT ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION IJ P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 COPM R U (Complete in Triplicate) Application is hereby made;�to San Joaquin County for a permit to' consiruct and/or inatAll the vork herein described. This application is made in co4liance vith San Joaquin County Ordinance No. 549 and 1662 and the Rules aad Regulations of San Joaquin County Public Health Services. JobAddress5189 N. Aifalfa Street City Linden Lot Site/Acreage I Owner's Name Mable Moznett Address 5189 No Alfalfa Street Phone ContractorPurvis.#' Driller94ddrnC. P.O.Snst• 54,Llnden_ License No. 377923 Phone — TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well tD PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 ,F 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 I i Cl -Industrial ❑ Open Bottom ❑ Manteca ' Dia.•ol Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Decasifid I Specifications { M Public M Other ❑ Delta r De th 6flGrout Seal Type of Grout Irrigation Approx. Depth ID Eastern Surface Seal InstalierTvy l i Repair Work Done 0 Type of Pump Sub H-P, 20 State Work Done _ k Well Destruction ❑ Well Diameter Sealing Materiali Depth Depth" biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 0 DESTRUCTION G INo septic system permitted it public sewer is available within 200 feel.) Installation will serve: Residence— Commercial_ Other j Number of living units: Number of bedrooms + l Character of soil to a depth ofi3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Gl lo• _ Method of Disposal ` i Distance to nearest: Well Foundation Property Line 7 I LEACHING UNE ❑ No: $ Length of lines Total length/sire FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS it Depth Sire Number I SUMPS L1 , Distance to nearest: Well Foundation Property Line _ DISPOSAL PONOS ❑ f 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 r rules and fogulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, 10411'not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiving of 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 taws 'omla." ii The a licant m s call f II quir inspections. Complete drawing on reverse side. r Signed .e Title: .- - Corp. Sgcretg,ry Date: 2Z13Z91 i �IAL_ FOR DEPARTMENTUSE ONLY 2-11Application Accepted byDate-2—E1 Area Pit or Grout Inspection by Date Final Inspection byZpa Date Additional Comments. Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 I 10 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES f i 445 N SAN JOAQUIN, P O HOS 2006, STOCKTON, CA 05201FEE ' INFO AMOUNT,DUE AMOUNT nEMITTEO CASH CK RECEIVED BY DATE PERMII'N ` ,�