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08-08-90 03: 18PM FROM TEOENG F06 APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOC&TONt CA 85201 PERMIT EXPIRES 1 YEAR XROM PAIS ISSUED (Complete in Triplicate) Application la hereby made to Sm Joaquin County for a permit to construct and/or install the work herein described, This application 1a made in caepliance with San Joaquin County Ordinance No, 549 and 1862 and the Rules Lod Regulations of San Joaquin County Public Health Serviaa. dr Job Address 2=1=A&e Xu&e ��L! - City:520*_qT~Lot Size/Acreage aaT'o o.,x 7PW 06r.0�1 rR.arC'bT3' ��r ,L 3�—• I� Owner's Name�GOele.22.b .�dresit �1 �� 4•aaE."i�:kzg Phonp a'IOC4V7VAoO, G9 aPX Zo/ Coniratlor eY.��..lfr gS Ud Address i��_Q r2. d�� License No,�e+�9s i Phufi y TYPE OF WELUPU_MP: NEW WELL C WELL REPLACEMENT C DESTRUCTION OOf Service well 0 PUMP INSTALLATION C SYSTEM REP918 ❑ OTHER O C onitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /00 DISPOSAL FLO. a PROP. LINE ZgW' FOUNDATION AGRICULTURE WELL '~ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom O Manteca Dig. of Well Excavation Dia, of Well Casing Ci Domestic/Private C Gravel Pack O Tracy Type of Casing Specifications I'I Public fl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Saul Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction 0 Well Diameter 13ke �� Battling Material a Depth Depth Piller Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITION ! I DESTRUCTION I I (No septic system permitted if public tower is available within 200 feet,) Installation will some: Residence_., Commercial— Other Number of living units: _ Number of bedrooms Character Of Goll to a depth of 3 fest: Water table depth 99PTIC TANK O Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT,0 Method of Disposal Distance to nearest: Well Foundation Property Line_ LEACHING LINE O No. A Length of line Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Siae Number SUMPS LI Distance to nearest: Will Foundation Property Lin• DISPOSAL PONDS C I hereby certify that 1 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 Sen 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, 1 shall not employ any portion in such manner as to become subject to workmen's compensation laws of California,"Contractor's hiring or aub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is lesued, I shall employ persona subject to workman's compenas- tion laws of California." The applicant mu all for all requir d I cti s. o late drawing on reverse Side. signs - eL, ` Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _ Applicant - Return all copies tot San Joaquin County Public Health Services, Eavironmental Health Permit/Services 1601 E. Hazelton Ave.. P 0 Hog 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I rK INFO I I CASIH I RECEIVED BY I DATE PERMIT'NO.