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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH S3;RyICTsSRE C g ENVIRONMENTAL HEALTH DIVISION E I I f 445 N SAN JOAQUIN, PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 OCT 0 8 1992 PERMIT ENVIRONMENTAL HEALTH l �E%PIRTs,S 1 YEAR FROIdD�,TE ISSUF�D PERMIT/SERVICES I (Complete in Triplicate} 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 Health Sere with Ban Joaquin County Or Hance No. 549 and 1$62 and the Rules d Aeguiat�ono of San I Joaquin County Public Hgealtph 8ervicee. ��C.t�tsf-�i6tevl� 1s�E(L ��,,�/�Jl Job Address 99 g I S 4-GIQ9Rcte_ D2 City C Lot Size/Acreage I Zo-i L{ sQ0 Owner's Name 7�C- IA 9��_ � � CO . Address �L? t ne 171 -�349rF � F !�9 � Contractor 1ELF Address License No, Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 2� PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHEfl ❑ Monitoring Well ❑ i, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `r �FO.UNDATION -AGRICULT-URE WELL_ -O CHER WELL: _PITS/SUMPS_ �r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing it Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public [:1 Other (l Delta Depth of Grout Seal Type of Grout rox 1 I Irrigation � App . Depth I I Eastern Surface Seal Installed-by Repair Work Done ❑ Type of Pump H.P. �' State Work Done, 1 Well Destruction O Well Diameter A Sealing Material Z Depth Depth i Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I f REPAiRlADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is i `I available within 200 feelJ Installation will serve: Residence— Commercial— Other Number of livi .a: Number of bedrooms ' + Character of sod to a dep feet: i . ester tabledepth � i SEPTIC TANK. 0 Type/M - +Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal ? i Distance to nearest: Well _oundation Property Line I� LEACHING LINE C1 No. 11 Length qt I' -' Total length/size FILTER BED ❑ Dista rest: Well Foundation rty Lina ? i SEEPAGE PITS 'I Depth I Sire Number ° SUMPS LI Distance to nsirest::.-, .. Well _Foundation �- Pro b DISPOSAL PONDS �o _ _ {�ertY Lina` v 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin countdi rubs and regulations of the San Joaquin County y ornances, $Iota laws, and I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this employ an permit is issued, I shall not p y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or nub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 Shall employ persons subject to workmen's compensa- tion b o Ilfornla." f The pplica t at all I r ct n Complete drawing on reverse side. Sig TXitle: M+WA- Date: Z Z F;e. FOR DEPARTMENT USE ONLY Application Accepted by Data Area -2/6 Pit or Grout Inspection by Date Final Inspection by Date�V Additional Comments: ! i Applicant - Return all copies to: San Joaquin County Public Health Services ` + Ii Environmental Health Permit/Services e foQ 1111 445 N Sao Joaquin Hox sons, Stka, CA 9520i n FE2PINFO AMOUNT DUE YAMOVNT REMITTED CK RECEIVED BYjDATjEJMes"'S �d EM 1}II tREV.i i w 51 W[J Z®. � EH 1 .,E i 'r I 1