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APPLICATION FOR PERMIT � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESs,* , ENVIRONMENTAL HEALTH DIVISION tr 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 'OC T 2 2 1992 SAN JCAQUtN PERMIT E%PIRES 1 C . 1, 'EAR FROM DATE ISSUED, P BLICNTqfEFV(Complete in ENVINlCE Triplicate) S RONEA7"N Pi Application is hereby made.to San Joaquin County;for a permit to construct and/or install the work herein describedh Wk4fv application is made in compliance frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. pl _ � City Lot Size/Acreage Job Address • LizPhone Owner's Name Address Mid l1 Ott. ;6 111License No Contractor Address fv ' .��Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ .DESTRUCTION ❑ out of well Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ ❑ i SEWER LINES DISPOSAL' FLD. PROP. LINE I DISTANCE TO NEAREST: SEPTIC TANK + f ^ AGRICtJ TI;JRE�WEL-L- ��`OTHER WELT PiTSISUMPS-�. —FOUNDATION--`� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPEC-FfiG*TNS Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing.1 ; LI Industrial ❑ ! T of Casing_ , Specifications i `>(Domestic/Private ❑ Gravel Pack ❑ Tracy Type Type aY Grout k I'I Ptrbfic [:1 Other F1 Delta Depth of Grout Sea] 3 `J I I Irrigation ____Approx. Depth l ] Eastern sea 5aal Installed by 1 I Repair Work Done 0 Type of Pump "� H.P. Stats Work Dane � S� i Sealing Material i Depth ' l - Won Destruction ❑ Well Diameter r t Dept - r 't- Tiller Material i Depth ` ' : TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I pEvailable+w thin 200 festsyste1leaif publ]csewer is I Installation will serve: Residence Commercial� Other r ' 4 Num of living unity. l Number of bedrooms'• i Character of'Soli to a depth of,3 feet: Water table depth 'r SEPTIC TANS O Type /Mfg _Capacity No. Compartments Method of Disposer ' PKG. TREATMENT PLT. ❑ ' " r I � i f Distance to nearest: Well Foundation Property Lina t -'f'Ler-g-l- Total length/size ' r LEACHING L` �C1'No: 6 Length of lines'- � FILTER BED D "Distance to;,nearest:" Well t Foundation k Property Line SEEPAGE PITS I I Depth Size Number '.- --,+ SUMPS__ 1 1.."Distance-to nearest: Well 1.-- -Found st ion DISPOSAL PONDS ❑ '>L" `:" I hereby certify that I have prepared this application and,that the work wifl be done in'accordance with San Joaquin countyordinances, state laws, and rules and regulations of the San Joaquin County '� f Home owner or licensed agent's signature certifies tlia following: "I certify that in the performance of the work for which this permit is issued, l shall not employ any person such manner as to become subpot to w&kmttn's'C_0TM isatii5rf taws of California."Contractor's hiring ar sub-contracting signature cettlfies the folbwi "I unity that in the performanc*of the work for which this permit is issued, I shall employ persons subj ect sa to workman's compen tion laws of C �- i. i The.4 ica i:bill-for-ail-requ inspec' s Complete-drawing on-rev -sides F 5_ y Title: Date: Sgned FOR DEPARTME T USE ONLY ,fes-��Aree'""��-_----�-W----•�-'.. I �-••-ApplicationAccaptad-by—~~ - �" `"-"`�""`-._T_...r----.-----••" - --Date- Pit or Grout Inspection by Date Final Inspection by qj Date l- 2 Additional Comments: Applicant - Return all copies to; San Joaquin County'Public Health Services Environmental Health Permit/Services 445,N San Joaquin, P 0 Box 2009, Stkn, CA 95201 e FEEKAMOUNTlJE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'ND. INFO • EK 1781IRtY.r�esi KJC� �6, ��`� tM 1476