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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 I ;.• "' "` (209) 468-3447 PERMIT E%PIRES I YEAR OROM DATE ISSUED SEP 28 1990 (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the' C TJ ifbed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Ru to, triode of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage 1�Z5'x- 7T Owner's Name Address 1 PhoneC Corrtrbttor ,EALC1:4akL �r_ Address License No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLA EMENT 0 DESTRUCTION JE Out of Service Well ❑ PUMP INSTALLATION ❑ '' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f.7 Industrial ❑ Open Bottom 91 Manteca Dia. of Well Excavation Dia. of Well Casing LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public I*.1 Other © Delta Depth of Grout Seal Type of Grout M IrriUation — Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ / Well Destruction tIQ Well Diameter rf.'...�L Sealing Material & Depth 1C4.�� rg-ffs _r;$tiw:�t�t rcId rewooe.� C Depth Filler Material i Depth p�c4r/r, a��ow TYPE OF SEPTIC WORK: NEW INSTALLATION ID REPAIR/ADDITION 0 DESTRUCTION EJ (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of $oil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line �J LEACHING LINE LD No. & Length of lines Total length/size , FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS i l Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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'ir�Writanner as to becom-Csubject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature certifies the flowing: ''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 o California. The appli an must call for bq requi dins omplete drawing onre se side. Q Signed Title _ Date: ��-2 '( FOR DEPARTMENT USE ONLY Application Accepted by _ Date 90 Area ZI- Pit or Grout Inspection by Date Final Inspection by_ _ ll . 494 OVA Data 9.2 T 90 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 AMOUNT DUE AMOUNT REMtTTEO RECEIVED BY DATE PERMIT'N0, INFO H EH 13,24 04EV.1INS)