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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED ENVIRONMENTAL HEALTH DIVISION N O Y 0 g 1992 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 5AN .iOAQUIN! CCLII'TY PUIRLI;; HEALTH S-7-RVICES PERMIT EXPIRES I YEAR FROM DATE MUM EN1 IP0NMENTAL HEh-FH DIVISION (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 catnpliance vith San o u n/County 0�'nance No. 51+9 and lab2_and the Rules and Regulations of San i Joaquin County Public Health Services. 4l ! !� 1 Job Address -ww s City 4dzWe Lot Size/Acreage i Owner's Name —M %1LJ"FEAMA Address Contractor _ i -f�f7�/G7�� tkess s' � � Phone nse No. TYPE Of WELL/PUMP: NEW WELL © WELL RE-PLACEMENT n DESTRUCTION Out of Service well L7 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public l-1 Other n Delta Depth of Grout Seal Type of Grout + } I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. = S1416 Work Done Well Destruction Well Diameter �_ Sealing Material i Depth Depth tiller Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is �^ available within 200 lest.) �J '^ - Flnstallation-wNi serve:--�-Residenee--Commercial— Other Number of living units: Number of bedrooms i Character of 601 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. a Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth Size Number ) SUMPS LI . Distorkow 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 Sen 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion lama of California." The appiic t fordl uked inspection&. Complete drawing on r rse side �f I Signed Title: Date Y Application Accepted by e Date res Pit or Grout Inspection by Date. Final Inspection b Datil/ Additional Comments: "ApplicAnt - Return all copies to: San Joaquin County Public Health Services ._a,._gnvironmental-Health Permit/Services - 445 N San Joaquin, P O Box 2009, Stkn, CA 95201. FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY D TE PERMIT NO. INFO �,/ • EN tS-26IREV.tiNSr /J/_ ENu•2& /t�J /