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F APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENTENVIRONMENTAL HEALTH DIVISION �I 1601 E. HAZELTON AVE. , PHONE (209)468-3420 RECEIVED P 0 BOX 2009, STOCKTON, CA 95201 OCT 01 9990 YPERMIT EXPIRES 1 YEAR FROM DATE ED SAN 10Af)!!I N, 't.)!;CITY (Complete in Triplicate) PUBLIC HEALTH SEP/IC S ii. ENVIRONMENTAL HEAL'I'I't DIVISION 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health services. Job Address a!�-9—Ce I City Lot Size/Acreage Owner's Name Address w . ;M&'�hone r y,,�` Contractor 114, } k Address r �[U License No. phone 07 TYPE OF WELL/PUMP: :h: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP i INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER fes' 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 cp n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i Domestic/Private 0 Gravef'Pack 11 Trac r ,Type of Casing Specifications Q r I') Public f:1,O:ther n Delta- '-Depth of Grout Seal Type of Grout q I i Irri ation - z, 4q t! plirax. Depth I i Eastern Surface Seal Installed by j Repair Work Dane 0 Type of Pump H.P. _ tate Work ne 'iYyt Well Destruction ❑- Well.Diameter ';+ Sealing Material & Dept Depth'I' `' ' " Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION:[ )•-REPAIR/A'DDITION i I DESTRUCTION I I INo septic system permitted:if public sewer is 11 1 available within 200 feet.) A P v` ? } ava t i r Installation will serve: R sidence^'Commercial----� ;Other Number of living units: J ��Number of bedrooms "" Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK. ❑ Type/Mfg Capacity_. No. Compartments PKG. TREATMENT PLT. ❑ it ^ " Method of Disposal Distance to nearest: Well Foundation Property Line i w 10 f LEACHING LINE 0' No.":& Length of lines Total length/size FILTER BED ❑ Distance to nearest.:. Well Foundation Property Line SEEPAGE PITS I I Depth Size Number '11%SUMPS "' CI . 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 Is 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 inheuch mannar-as to become subject to workman's compensation laws of California."-Contractor's-hiring or=sull'contracting 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." ¢ rq . ,�, The applicant ust cal r all required inspections. Complete drawing on ri erse side. ¢ ; Signed r Title: „ Date: iV F07 DEPARTMENT USE ONLY A Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Da Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. . EH1CMtREV.tikslC S1Z ��l3`40