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APPLICATION FOR PERMIT - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t � ENVIRONMENTAL HEALTH DIVISION 0� P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 MAR 3 0 1992 r PERMIT EXPIRES 1_Y13AR kROM DATE IkaM ENVIRONNilIEA I Irl•;. HAEALTH (Complete in Triplicate) PERMIT/sEFNICES 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 coWliancelvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. JobAddress t ��1s� Buri` - --''City Lot Size/Acreage] � p-e�'r5 Owner's Name Address 7"-� '[ �t, arm r ___ Phon �rVZ5 2 Z i Contracto dress icense No. Iya2i_Phon TYPE OF WELL/PUMP. _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl Monitoring Well S PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER nSL CJ .G .� .� �?r�� w u�a�r DISTANCE TO�EAREST: SEPTIC TANK' 00 SEWER LINES /DO DISPOSAL FLD. L�.._ PROP. LINE � S, ..y�L` FOUNDATION AGRICULTURE WELL � OTHER WELL a PITS/SUMPS �// INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !C fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CJ Domestic/Private Cl Gravel.Pack.. n Tracy Type of Casing Specifications R Public f'1 Other © Delta Depth of Grout Seal Type of Grout i G Irrigation —Approx• Depth 0 Eastern Surface Soul Installed by t Repair Work Done D Type of Pump 1 H,P. State Work Done Well Destruction O Weft Diameter Sealing Material l< Depth {�s Depth `f Filler Material i Depth TYPE OF SEPTIC WORK:. NEW INSTALLATION 0 REPAIR/ADDITION Cl DESTRUCTION CI (No septic system permuted if public sewer rs available within 206 feet.) installation will serve: Residence ..' Commercial'_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK' .0 Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. 0 �� Method of Disposal Distance to nearest: Well Foundation Property Line I� LEACHING LINE ❑ No. 6 Length of lines Total length/size I � FILTER BED n Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line ) DISPOSAL PONDS ❑ J t 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 Son 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 1 certiflea the foflowin4: 1 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 Intlat call for all (squired inspections. Complete drawing on reverse Side, Signed Title: Date: T 6L l° MENT USE ONLY Application Accepted by Date a�� V Pit or Grout Inspection by Date Final_Inspection by Date Additional Comments, Applicant ^ Return all copies to: +SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA' 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASCK H 'RECEIVED BY DATE PERMIT NO. . EH 13.24 IREV,i i n sr