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r ¢ APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �y ENVIRONMENTAL HEALTH DIVISION D p O BOX 2009, STOCKTON, CA 95201 PAYMENT (209) 468-3447 RECEIVED PERMIT SPIRES 1 YEAR PROM DATE ISSUED Sip 1 8 1992. (Complete in Triplicate) UIN�C;l " , SAN JOAQ Application In hereby made,to San Joaquin County for a permit to construct and/or install the vox�k $if1�L �d1.; RV�ie application is Slade in eaiagiliance with San Joaquin County Ordinance No. 549 and 1862 and the Rulas��pjNl� a of Ban Joaquin County Public Health Services. L'`�� Job Address _..C)_; City t Size/Acreage Owner's Name Address Phone � � ��- P Contract Addres ES�ItL(o ►d+L?rK +eta.- 'z�cense N Phone 54 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 0 DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR tl✓ OTHER O Monitoring Well L� 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 1:1 In ial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private O Gravel Pack O Tracy Type of Casing Specifications M Public Cl Other O Delta Depth of Grout Seal Type of Grout G Irrigation Approx. Depth ❑ Eastern 8 Surface Seal Installed by Repair Work Done Wo Type of Pump .�— H.P. _ _ State Work Done U942A Id Well Destruction O Well Diameter Be ing i Depth Depth Tiller Material 4 Depth "V TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DES UCTION M INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other (!�, Number of living units: Number of bedrooms Y_J Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. 8 Length of lines Total length/size FILTER BED CP Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONOS O 1 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 rubs 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 in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub contract ng 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 applicant must cal r required intpgctio . Complete drawing on,raver side. Signed Title: Date: FOR DEPARTMENT USE ONLY 9A '/?2-Application Accepted by Date Area -14 Pit or Grout Inspection by Date Final Inspection by Data 4� Additional Comments: _ Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX-.40 9, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMO�UNjT'REMITTED K RECEIVED BY DATE PERMIT'NO. . EH 13-24 IRIV.1/45) poopLf � T". b szszF�72 L g ?2- GGL7 EH;1.21