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�A APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EENVIRONMENTAL HEALTH DIVISION CE 1601 P•OHAZELTON BOX 2009,�VE. , PHONE STOCKTON, CA095201-3420 SEP 1 8 1992 } 2XMIT EXPIRES 1 VRAR FRQH DATE ISS ENVIRONMENTAL HEALTH (Complete in Triplicate) PERM IT/Se Rv s Application ishereby 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 Joe uin Co ty Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services., � ��s' �r� r Joh Addres J"� dE City -Lot Size/Acreage Owner's Name �+ `�� `� Q- Address yy,�,,�r Phone v P dL Contractor Address +'V. ens ��"L--._ 1.1F_+�1 Na one TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT p DESTRUCTION 0 Out of Service Well ❑ + If PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE 70 NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing # e El Domestic/Private ❑ Gravel Pack El Trac Type ype of Casing Specifications V1 Puglia Cl Other Cl Delta Depth of Grout Seal Type of Grout Irrigation _ Approx. Dep h I I Eastern �S�u^r^face Seal Installed by Repair Work Done U Type of Pump H.P. - 1 - State Work Done Well Destruction ❑ Well Diameter - - Sealing Material & Bepth Depth t Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I iNo septic system permitted if public sewer is Installation will serve: Residence-I Commercial Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg.I Capacity No. Compartments PKG. TREATMENT PLT. ❑ , �. Method of Disposal Distani:6 6 nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welli Foundation Property Line SEEPAGE PITS 11 Depth I Size Number SUMPS LI Distance to' 'nearest: Welt Foundation Pro DISPOSAL PONDS ❑ r� Party Line I hereby certify that I have prepared this apptication 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 parson in such manner as to 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 Califo Ia.- I The applicant ust c 11 to II requir ins pe ti ns, mplet rawingo re arse side. Signed X `Title• Date: FO E'ONLY Application Accepted by Date e� Arse Pit or Grout inspection by Date Final Inspection Date�� Additional Comments: Applicant Return all copies to: San Joaquin County Public Health :Services, &vironmental Health Permit/Services 1601 R. Hazelton Ave., P 2009, Stockton, CA 95201 F A OUNT DUE A OUMT REMITTED CK RECEi BY ATE/- PERMIT NO. . EH 13-21 rRSV.,/x 51 ' ` . EH 14"2E 1,g,%