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APPLICATION FOR PERMIT SAN JQQ�AAA�UIN COUNTY PUBLIC HEALTH :;nRVICES — PAYMCl7TIRONMENTAL HEALTH DIVISION R � ft ZELTON AVE. , PHONE (209)468-3420 �O% 2009, STOCKTON, CA 95201 APR 2 5 1990 O� SAN JO RES 1 YEAR F ROM DATE 1391119 PUBLIC EALTcHnSEE7iRl�11� C Tete in Triplicate) Application Is hereby ��R� � b�tr'COfriltyvf6Y"a permit to construct and/or Install a wo ei described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and L es d Regulzitione of San Joaquin County Public Health Services. �/n fixE� Lot Size/Acreage Job Address City� Owner's Name ?r</! Address �` ` 1 fl�, w FIVY Phone C6o2) ( JF ILG 3kr=oS£� i 5 t zly Address LZ'ZZ .S di�vn /Ul License No. Phone Contractor y45 �fN/(6 ervice Well L1 TYPE OF WELI/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DES TRUCTION Out t4ao Loring Nell PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O 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 f I Industrial El Open Bottom L1 Manteca Dia. of Well Excavation Dia. of Well Casing (i Domestic/Private LIGravel Pack 0 Tracy Type of Casing Specifications — 1 Public ❑ Other n Delta Depth of Grout Seal _ Type of Grout — i I litigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump -1— H.P. State Work Done C _ ,,...Jy Sealing Material i Depth 1 Well Destruction Well Diameter —.F-- I`3 Depth Filler Materiel i Depth r TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No ailablseptic system hin m feet.)permitted it Public sewer is (� Installation will serve: Residence— Commercial_ Other I Number of living units: _ Number of bedrooms Character of soil to a depth at 3 teat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line , LEACHING LINE ❑ No. i Length of lines Total length/size FILTER BED CI Distance to neatest: well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 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 California ' j The applic� `my I/for all required Inspections. Complete drawing on reverse side./ Signed X _— - 71615•r.. SS?�G� Title: /ice o '3,ue— Date: i iB0 P MENT USE ONLY Application Accepted by Date shy — C Area _ .,,C---- Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health .yA�dh+� Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED 1: DATE rc� RMIT'NO. INFO ^ /`�•� E� Q . EN 1J-111REV.1/n$) `� �� C v' 4 `d ,Z� EH /_Te «�...JJJ