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` APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC �" � r e ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 MAY 2 D 1.991 F � (Complete in Triplicate) RGNi1/1E�,fA�.. HEALTH - RFRMIi-t'r/'.;%,ERVICFrS Application is hereby made to San Joaquin County for &-permit to construct and/or install the work herein described. This application Is made in coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County /Public Health Services. Job.Address C LJ IJ' �` V ity Lot-Site/Acreage Owner's Name `, 11�STlgL LO l U Address _ L� ''J I �Lti�� - Phone U �` 43. IV. &4 L3 License lvo. 5 _Phone Contractor- n]I J d CJ SAL t�f __Address TYPE OF,WELL/PUMP: NEW WELL ❑ V ELL'REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well C❑ PUMP INSTALLATION ❑ 4 SYSTEM REPAIR OTHER ❑ lKoeitoring Well DISTANCE TD NEAREST:,.SEPTIC TANK SEWER LINES _- DISPOSAL FLD. f PROP. LINT; ' FOUNDATION AGRICULTURE VVELL_.i OTHER WELL Y PITS/SUMPS INTENDED USE-y TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n n Industrial ❑ Open Bottom © Manteca O-s:ol'Well-Excavation --— Dia. of Well Casing " CJ Domestic/Private Cl Gravel Pack ❑ Tracy I Typa_of Casing" 'i _ r Specifications M Public i 1:7 Other ❑ Delta � Depth of Grout�Soal _._ Type of Grout VInigalion _.Approx. Depth C] Eastern ISurface,Saul Instatl4d by Repair Work Done U Type of Pump r�2�. _ H.P, f U 4# State Work Done -t rr Sealing Material Z Depth �ij Wfr - ell Destruction ❑ Well Diameter t ti. Depth Filler Material i Depth } TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION G.(No septic-system permitied if public sewer is I I available within 200 feet.) - installation*11 serve: • Residence_ Commercial Other r - �- Ii ... .�., - Number of living units: Number of bedrooms i r r f Character of $oil'to a depth of 3 feet: i - Water table depth SEPTIC TANK 0 Type/Mfg ! Capacity - - No. Compartments PKG. TREATMENT PLT. 0 _ Method of Disposal Distance to nearest; Well 1�yFoundation � Property Line F+W LEACHING LINE C1 No. & Length of lines i Total length/size FILTER BED n Distance to nearest; Well - i Foundation Property Line + SEEPAGE PITS 11 Depth Size t Number ;�o-SUMPS L:] Distance to nearest: Well' Foundation Property Line DISPOSAL PONDS © I hereby certify that I have prepared this application and that the worklwill be done in accordance with San Joaquin county ordinances, state laws, and w. rules sntl 49ulatidffi df-the-San Joaquin'Counq; I 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 i' employ any person in such manner as to become subject to vyorkman's compensation laws of'Celiiornia:" Contractor's hirih nr st7ti=conti&cting signature certifies the following: 1 cenify that in the performance of the'work for which this permit is issued. I shalt employ persona subject to workman's compensa- tion laws of ilia n1a." f The applic t t call for all regtlr inspect' s. Complete drawing An rev ra side. ' Signed f Title: Date: I j R DEPARTMENT USE ONLY Application Accepted by I Date -� �/ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments. f 1 Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES HEALTH-DIVISION-PERM IT/SERVI-GES-. - -K 445 N SAN JOAQUIN, P O BOX 2098, STOCKTON, CA 85201 FEE r INFO AMOUNT DUE /AMOUNT REMITTED CASH EC HEEVeo ay DATES jP;EAM.IT'N0. EH 13.24 IREY.r i n 5l EH i{•�