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t N APPLICATION FOR PERMIT D SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECE �r ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOC%TON, CA 95201 ,J U L 1 1991 (209) 468-3447 ENVIRONMENTAL HEALTH U PENIT BUTARS 1YEAR ?ROM DATE- ISUED PERMi T L iVi,i.J (Complete in Triplicate) Application is hereby stsda t0 San Joaquin County for n permit to construct and/or install the work herein described. This application is Stade in cmwliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health services. Lot size/Acreage Job Address City �Owner's Name7— (-.- Q,�� f _ Address Phone r -Z— e� Contractor Address c�� c C?Swficense No. Pho^ TYPE OF WELL/PUMP: �� NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well CI PUMP INSTALLATION S--' SYSTEM REPAIR OTHER ❑ Monitoring Well Ll DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tDia. of Well Casing C7 Ind rel ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 tic/private Cl Gravel Pack C] Tracy Type of Casing Specifications Public 17 Other ❑ Delta Depth of Grout Seal Type of Grout $ M Irrioation � .Approx. Depth n Eastern I Surface Seal Installed by f(�' Repair Work Done 0 type of Pump H.P.��: /� _ State Work Done [Jl Well Destruction ❑ Well Diameter Sealing Material i Depth ' Depth Filler Material i Depth `; TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION GI (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence Commercial= Number of living units: I Number of bedrooms Character of soil to a depth of 3�ast:" ^"'' ^ - — Water table depth 41 SEPTIC TANK. ❑ -iIType/Mfg No. Compartments PKG. TREATMENT PLT. Q Method of Diitposal- - Distance to nearest: Well Foundation. Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED n 'i Distance to nearest. Well Foundation Property Line SEEPAGE PITS' I Ii,Depth Size Number SUMPS ! _: LI i Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ ii 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 iubject to workman's compensa- tion laws of California." j! The applicant must call o H required in actions. Complete drawing on verse side. Signed X_ Title: Date:FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Dets 7 g Additional Comments: II Applicant - Return all Copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES L ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES III 445 H SAN JOAQUIN, P 0 BOX 2009, STUCKTON, CA 95201 s FEE AMOUNT DUE AMOUNT REMITTED CK 8 CASH RECEIVED BY DATE PERMIT NO, INFO u�/ I r 7 EH 111-24 IpEV.1/14 p1 LS c"o EN 7 .26