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APPLICATION FOR PERMIT 3 , SAN JOAQUIN COUNTY'PblitIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 p,M I T ESP I RES I YTsAR Ir --QbL DA��,�� (Complete in Triplicate) Application is hereby made.to SanJoaquin County for a permit to construct and/or install the work herein described. This application In made in compliancq;with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County eP�ublic Health Services. Job Address _ T�90 V,FL 2le-6 City Lot Size/Acreage r - - Owner's Name MIZ_f1 9S S MAL�WAddress JPhone Contractor Address/I"\,./, License No.��Q�S`9 Phone '7�!^7/' 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ 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 p: INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic I Private ❑ Gravel Pack WTracy Type of Casing Specifications M Public I11 Other 0 Delta Depth of Grout Seal Type of Grout CJ irrigalion .:Approx. Depth O Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump. H.P. State Work Done Well Destruction C Well Diameter. Sealing Material & Depth Depth 1 Filler Material fir Depth TYPE OF SEPTIC WORK; NEW INSTALLATION Ll REPAIR/ADOITIONA DESTRUCTION 0 (No septic system permitted if public sewer is available within 200 feet.) Installation wilt serve; Residence Commercial Cher Number of living units: Number of b rooms l Character of soil to a depth of 3 test: : CkAl_ Water table depth O SEPTIC TANKType/Mfg f Capacity No. Compartments Z PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Fo�ndation Property Line LEACHING LINE Vf_ No. & Lenpth of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation L21 Property Line . u SEEPAGE PITS l Depth 5i re Number SUMPS LI Distance to nearest: Well C_uy Foundation ._ _ t Property Line E f DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application n 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 in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-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 Califor la.' The applicant m all for eq d ins tions. Complete drawing on reverse side Signed �— Title: _ -�� T � Date: __1_s2 /G,-,�J,R FOR T-USE ONLY { Application Accepted by _ 4s�� * _. .�� Date 5_97) Area Pit or Grout Inspection by Date Final Inspection byCa f +�' pate Additional Comments; _ Applicant - Return a.11 copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ��/9 90/ 'M`t '?6 -Sa�� ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE )NFO AMOUNT DUE AMOUNT AEMtTTED CASH RECEIVED BY DATE PEAMiT'NO.