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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SHRVICHS ENVIRONMENTAL HEALTH DIVISION PAYMENT 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O sox 2009, STOCKTON, CA 95201 RECEIVED IT Zulus 1 YEAR FROG DATE ISSUED SEP 19 1990 (Complete in Triplicate) SAN JOAQUIN COUN?Y PUBLIC HEALTH SEW Application is hereby tmade,to Stan Joaquin County for a permit to construct and/or install the �►�g�t�� ON vil application is made in ceance vith San Joaquin County Ordinance No. 549 and 1862 and the u es an egu ons o a Joaquin County Public Health Services. r Job Address d-p(l A ,qTien City L�n Lot Size/Acreage 15'T �LC{ Owner's Name FocAddress��` 1 b J k% PK..- - 2S.L5 E M9rfle Ste- Contractor et. Address r1 CA License No.512Z/03 Phone 919 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER*A(5Monitoring Well - OIL.. $c+/rJN`p5 DISTANCE TO NEAREST: SEPTIC TANK S SEWER LINES 260 DISPOSAL FLD>_55O PROP. LINE3__50R-/ FOUNDATION d ._ ,AGRICULTURE WELL a OTHER WELL�� PITS/SUMPZ-5 fAr:0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 13 n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing 5k6 ~/ 11 Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications 11 Public Cl Other it Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by j etr.Yxidann Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material Z Depth CC+rvt Depth Filler Material fi Depth 6W_Pu '7 {g±d M 7Y' Su . TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Rasldenee dOMMarelal_. Other Number of living units: Number of bedrooms Character of toll to a depth of J feet! tl Water table depth SEPTIC TANK d Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O Nb. S Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 4agulatioris of the San Joaquin County, Home owner or licen 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 mannar,as t0 become subject to Workman's compensation laws of California."Contractor's hiring or subcontracting 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- tion laws of California.,, The applies t call for at eq 1pictiont. C plate drawing on reverse side. i SignedTitle: Date: /�18 /!7 s- - .FOR DEPAnTmENT USE ONLY AppGcation Accepted byv- dMulfie Date Area �� _ Pit or Grout Inspection by Data Final Inspection by Date /C L Additional Comments: Applicant - Return all copies tot San Joaquin County` Public Health Services, taviroftental Health Permit/Servicer 1601 H. Hazelton Ave., P O-Bkox 2009, Stockton, CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO / `p . EN 1321tREV.tin5) Q I' fa[O L,? 2"