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1 / APPLICATION FOR PERMI, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete is Triplicate) Application is hereby mede,to San Joaquin County for a permit to construct and/or install the vork 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 Servv-iices. ` ,,��c c Job Address NW CV'*4r CW Damon a ""a^�' �,tr' City Jv�J Lot -Size/Acreage Lt Owner'sq— Name ` +u �' S� hm Address 3D5 /l' E 1 QOrnd 0 / SjDCk v r r Phone 9T 7 Contracts S Address �S S • �►kicense No.5965L,15 Ph,ne�1 TYPE OF WELL/PUMP: NEW WELIS QQ WELL REPLACEMENT ❑ DESTRUCTION O Out of Seryice Vela O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring We11S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Q/ C3) FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial �0 Open Bottom D Manteca Dia. of Well Excavation 10Dia. of Well Casing * Domestic/Private bf Gravel Pack O Tracy Type of Casing Pyr, Specifications 8D 1'1 Public Cl Other FrDelta Depth of Grout Seal 23/ Type of Grout i I I�I r�ati�oo.� �Approx. Depth 1 I Eastern Surface Seal Installed by Repan VDti'htn2,n� U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Tiller Material i Depth r- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo 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 X SEPTIC TANK O Type/Mfg Capacity--- No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line PAYMENT LEACHING LINE O No. 8 Length of lines Total length/size RECEIVED FILTER BED O Distance to nearest: Well Foundation Property Line F F R 0 3 1992 SEEPAGE PITS I I Depth Size Number IN COL;NTY SUMPS LI Distance to nearest: Well Foundation Property Line—2118r1CHEALTH SERVICES DISPOSAL PONDS D ENVIRONMENTAL HEALTH DIVISIO 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, I shall employ persons subject to workman's compensa- tion laws of California." The applica st call for all required inspections. Complete drawing on reverse side. Q Signed ',�"',�` Title: P L I C 1'n b 1 O�� 01 l S Date: 13 I ✓ Z QNA 'HVLN1 rte �OR DEPARTMENT USE ONLY Application Accepted by Date /3-9y Area Pit or Grout Inspection �� i/3~f2 pection by Date 3 Final Inspection by Date Additional Comments: 74 .3 ACU Applicant — Return all copies to: San Joaquin County Public Health '1 A 5�j sF Services, 1nyironment:al Health Permit/Services d 1601 L. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 CK 8 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17 NO. EH 13.2 (REV. i.-,r &9/ P