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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESR E I ENVIRONMENTAL HEALTH DIVISION P 0 BOB 2009, STOCKTON, CA 95201 SEP 9 1991 (209) 468-3447 ENVIRONMENTAL HEALTH R eFLQX PATE ISSUIM PE-IRMI T/SIRV' tCL S (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application Is Stade in cotupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 37-3((.J o 1 City Lot Size/Acreage Owner's Name r � -"�� K'4—Address Phone c _ Contractor Address o eala:a 9S3Qffense No. ��. Phone S _ TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION E-- SYSTEM REPAIR L�Y' OTHER O Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f"1 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Womestic/Private C1 Gravel Pack n Tracy Type of Casing Specifications M Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout 0 Irrigation � Approx. Depth ❑ Eastern I Surface Seel Installed by Repair Work Done U;- �Type of Pump H,P. ICY` State Work Done 3 Weft Destruction O Well Diameter Sealing Material & Depth ytry' Depth Filler Material & Depth ra TYPE OF SEPTIC WORK: NEW INSTALLATION 1--) REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is (pWJry available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK '❑ Type/Mfg Capacity---- No. Compartments PKG. TREATMENT PLT, C1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance 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 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 sub-contracting signature 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- tlon laws of California." The applicant Tun-cq Tun—c # all required ins ctions, Complete drawing an reverse side. Signed �� Tide: C;tu� __- _ Date: b;e R DEPARTMENT USE ONLY Application Accepted by Data y Area Pit or Grout Inspection by ate Final Inspection by Date Additional Comments: Applicant - Return all copiers to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENNTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED_ CASH RECEIVED BY ] DATE PERM11 NO, . EH 13-24(REV,i/MSt PP OOHIV, �..s+nn to q( Ij �� `1� Eli 14•2e 1 P •v•�