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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESLtw ENVIRONMENTAL HEALTH DIVISION ad � 1601 E. HAZELTON AVE. , PHONE (209)468-3420 APR 8 1991 P 0 BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH PFRUIT-EXPIRES 1 YEAR FROM DATE ISSUEDPERM! =. (Complete in Triplicate) ��,4- -( 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Ser ices. 1 Job Address City Lot Size/Acreage Owner's Name Address 1 �U •OCLlSF- f 2gE _ Phone L I Address -3 —N= LA) License No: QLS_% T Phone TU94, — TYPE OF WELL/PUMP: NEW WELL CI WELL REPLACEMENT,❑ DESTRUCTION ❑ Out of :Service Well ❑ I PUMP INSTALLATION ❑--y SYSTEM REPAIR fy' OTHER ❑ Monitoring Well ❑ ' DISTANCE TO-NEAREST: -SEPTIC-TANK SEWER LINES- DISPOSAL FLD. l PROP. LINE FOUNDATION ry AGRICULTURE-WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ ¢pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ++ [r?"Domestic/Private Gravel Pack CJ Tracy Type of Casing�..w � Specifications CA I.1 Public C7 Other F1 Delta Depth of Grout Seal Type of Grout I i Irrigation Approx. Depth I I Eastern Surfs Seat installed by Repair Work pone U Type of Pump H.P. �.. Sista Work Done L } �� Sealing Material & Depth Weil Destruction ❑ Well Diameter - Depth Filler Material & Depth 4 TYPE OF SEPTIC WORK: NEW INSTALLATION ( 1 REPAIR/ADDITION 1 1 DESTRUCTION 11 (No septic system permitted iflpublic sewer is available within 200 feet. l i 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED Ell Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size — Number S E ^ SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS per. 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 Countyv If 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 noty, 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 followi "I certify that.in-the-performance of-the-work.for which this permit is issued, I shall employ persons subject to workman's corn a- t tion laws of Calico nia " i The applica mus all for all required Obvections, o plate drawing on revers 'de, _ Signed Title: Data: t FOR DEPARTMENTWE ONLY Application Accepted by 1evI Date ^� Area��r Pit or Grout Inspection by . gate Final Inspection by. 1 Date I # i t Additional Comments: Applicant - Return a.11 copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE I PERMIT NO. INFO CASH may)(� �J �� . EH 1324(REV.rrne) IV L� (/ .� •E7""r► �"� � EH 1426 r