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R t APPLICATIOW FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 ' ' •i3�. P O BOX 2009, STOCKTON, CA 95201 E CEI V E L 131� 113 %P RES 1 YTsAR FROld DAT AUG 1990 (Complete in Triplicate) _ Application is hereby made to San Joaquin County for i application is made in c Permit to construct and/or install the T,rorkthere0N krN b R A Is empllaere With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services, Job Address S�oa EA -F �,.� t-�� City LUb! Lot Size/Acreage Owner's Name 010r Ci+ t*yyL, E>409 EG + { Address w✓Ig Phone Contractor C j�� 95641 Address p d• I UX 1664W �e TYPE OF WELL/PUMP: ' AS ACC 'license No. #5557-11 3 Phone 916 313'!I1 NEW WELL WELL REPLACEMENT PUMP INSTALLATION ❑ DESTRUCTION L) Out of Service Well Ll 2do SYSTEM AFFAIR L7 OTHER ❑ Monitoring Wel] DISTANCE TO NEAREST: SEPTIC TANK •SEWER LINES '--- DISPOSAL FLD. 1JJA PROP. LINE FOUNDATION ZUo fi. AGRICULTURE WELL 1550 , �'�'C -r*.INTENDED USE TYPE OF WELL OTHER WELL=g(,,4 PITS/SUMAS iU PROBLEM AREA CONSTRUCTION SPECIFICATIONS f=J Industrial ❑ Open Bottom ❑ Man^ tacoExcavation, rr Dia. of Well �� - pia. of Wall Casing M Domestic/Private Gravel pack L7 Trac " �'• q� i'I Public y Type of Casing yG1,. -}O TVt�`„ Specifications .. fa Other n Delta Depth of Grout Seal 38 { O 1 I Irrigation .�... 1y+�*�..t Type of Grout wk _.Approx. Dept/�I ! Eastern Suri a Seat Installed by Fe�w.tn , Repair Work Done ❑ Type of Pump -mow err . H.P. State Work Done _ I� Well Destruction ❑ Well Diameter �r Sealing rial & Depth 6 •{' _ PIA , Depth__. 60 :'{ R Filler Material d Depth ( I ' f a^t. ltJtr. Mvvrfw�f S ,r. TYPE OF SEPTIC WORK: NEW INSTALLATION If AEPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer !s �. Installation e: Residence_ Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms_ Character of soil to a depth of 3 SEPTIC TANK. ❑ Type/MfgW a to depth PKG. TREATMENT PLT, ❑ Capacity No.ethod of Disposal Compartments M Distance to nearest: Well Found Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance t rest: Well Foundation Property Line SEEPAGE PITS I Depth Size SUMPS Number Distance to nearest: Well Foundation DIS L PONDS Cl Property Line 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 rn 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 t 1 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, 1 shall employ tion laws of Ca Ifo►nla." p p Y persons subject to workman's compensa- tion The a plicant st f r uire inspect' a drawing on reverse side. . � � Sig,ed xY sJi itle: ? Vis- ! i` ONLY pnDate: -4/012— �,�/} Q{7 DEPARTMENT USE Accepted by�G�Gt. _ FI/�JJ��l� g0 Date Area T'J Pit or Grout Inspection by Date JJFinal Inspection by Date 1 Additional Comments: 0 L)1&� I 1! Applicant - Return all copies to: q= Joaquin County Public Health f� Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK EH 13-21[REV. n Sl INFO CASH RECEIVED BY DATE PERMIT'N0. +iSl EH 21-2e (f a Y9qa ells-