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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PA Y ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 V D P 0 BOX 2009, STOCKTON, CA 95201 0 C T 2 1992 ,klfq JOA(Njliv PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �Li.f��{:�� r�? � L1�►7Y (Complete in Triplicate) lVV1RONM�' fjL_.E ' �'�4�IGS ,EEA I'hi DIVISlON A Application is hereby made to Sea Joaquin County for a permit to construct and/or install the work herein described. This i 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 Services. Job � — ."• � �'"'�"•�,•,,•• ` '` / e`„," - �w Job Address _ -7 &4&4-7 (to City !9M �N)Lot Size/Acreage �r ac- cr11 Owner's Name � �'� G ` 61P®O Address _ fT 7 KDI.i _ _ Phone — !i ,�{ t. Contractor T� �L_F Address s #q License No. Phone - I TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U 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 El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Dorneatic/Private ❑ Gravel Pack ❑ Tracy r Type of Casing_ Specifications I'1 Public f-1 Other Cl Delta r Depth of Grout Seal Type of Grout P t I Irrigation Approx. Depth I I Eastern Surface Seal installed byE Repair Work Done L] Type of Pump H.P. uAk — State Work Done x4st 14dU�a+-�—rtem - neI` Well Destruction ❑ Well Diameter -._Sealing Material A Depth �GII li Depth 1fi11er Material_i-Depth _ �. -•. .,�,,� �. Ill TYPE OF SEPtIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I i lNo septic system permitted if public sewer is available within 200 feet.) installation will terve: Residence_ Commercial__—_ Other II Number of living uni Number of bedrooms �I Character of soil to a depth o Water table SEPTIC TANK ❑ Type/Mfg Capacity a. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Ditlance to nearest: Well Property Line II i LEACHING LINE ❑ No, 8 Length of line Total length sl FILTER SED 0Distance to rest: Wel! Foundation Property Line SEEPAGE PITS th i Dep S:e Number SUMPS LI. Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ ; 1 I here cern that I have prepared this a i by certify p p application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and rules and regulations of the Sen Joaquin County i 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-signeturew 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 applicant ust call for all required inspections Complete drawing on reverse side. i Signed �� - Title: Date: 13 rjL- FMOR USE ONLY - Application Accepted by Date Area f� Pit or Grout Inspection by Data Final Inspection by Date*J01 2' Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services Ii 445 N San Joaquin, O Box 2009, Stkn, CA 95201FEE j INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMNf'"NO. . EH 1111(REV.t n 5i %.1• frT� � �� / r�I �•/"" L f� i��J 7c,?V EH 11•lti