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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC 111BALTIf SERVICES PAY E 7- ENVIRONMF.PITAL HEALTH DIVISION �� P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 OCT 1 3 1992 PUBLIC �AQI)INI COUNTY (Complete in Triplicate) DiVl4 if .R �ALTt,��:s;1�IC�S ONMIEPOAI_HEALTH DIVgg Application is hereby made,to Sap Joaquin County for a permit to construct and/or install the work herein described. T ie 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 Services. Job Address 2100 mat 3.5-`fi City J42 in� Lot Size/Acreage za ff c Es-hate o�A viy ! u z z0. ) Owner's Name CCtS Addross S30 � _`�gLC'S -_S.t"• �l.3l ,....._.._., Phonal: S -U D!5*erhev-} 2523 RtUer2«zj ,,If,�r Contractor S"rPWUr' Zfn� Address O +0 A gs35 License No44(.&7b Phones - Y7la TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 171 DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR 0 �O�THE.R p Monitoring Well x DISTANCE TO NEARS EST; SEPTIC TANK lYl� SEWER LINES 6 , DISPOSAL FLD,&/ _ PROP. LINE ZO-L FOUNDATION 30 ` AGRICULTURE WELL 664- OTHER WELL O PITS/SUMPS Z&I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i! L1 Industrial 0 Open Bottom (,$Manteca Dia. of Well Excavation � Dia. of Well Casing _2 (SQ Oomaslic/Private I Gravel Pack 0 Tracy Type of Casing \JL Speciiications fa Pvbfic 1:) Other 0 Delta Depth of Grout Seal 5012FAcf Type of Grou l'J Initiation „Approx, Depth ❑ Eastern Surface Soul Installed by Repair Work Done 0 Type of Pump H.P. Slate Work Done _ Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION C'I DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms r Character of soil to a depth of J loot: _..__.Water table depth h/`l SEPTIC TANK 0 Type/Mfg Capacity No, Companments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well ,�_ Foundation Property Line LEACHING LINE C] No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Welt Foundation Property Line SEEPAGE PITS 11 Depth Sila __.._, Number SUMPS Cl Distance to nearest: Welt Foundation Property Line DISPOSAL PONDS 0 I hereby aanify 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 Homs owner or licensed agent's signature conifies the following: "I certify.thal in the performance of she 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•contracling signature canities the following: "I cenify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's componsa- tion laws of Cslifomla." The applican s! c 11 for tequd i,s do s. Complete drawing averse side. Signed r Title: ` Dote: FOR DEPARTMENT USE ONLY ;;11 Application Accepted by V Data R� Area Pit or Grout trspection by Date �� /� Final Inspection by .7n Data Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES c� ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICER r}-� 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO CASH DATE PERMII'NO. Est�I.m