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APPLICATION FOR PERMIT I i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , .PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 I I. EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1562 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _ /10 ;oL11G1.4&1,+ / - ---- Cit CL1,JLot Size/Acreage t Owner's Name �/V Address 1� -- Phoney/ ''� '7S ContfactoA �tL061/ VAddres,&I&X IV3 C?HL y A141.A141. License N.4%6 P on; alb TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER O Monitoring Well ❑ 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 L1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing M [7 Domestic/Private D Gravel Pack 0 Tracy Type of Casing Specifications ` I'] Public C7 Other ❑ Delta Depth of Grout Seal Type of Grout N 4 t I irrigation —.Approx, Depth I I Eastern Surface Seal installed by N 4 Repair Work Done ❑ Type of Pump H.P. State Work Done_ (� Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION i I (No septic system permitted it public sewer is / ittvm 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: I_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth d c d SEPTIC TANK. 13 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of DiWal Distance to nearest: Well Foundation Property Line LEACHING LINE 97N0. & Length.of lines __- -____ _ ______-_ ___- _'_ Total length/sire + FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS Ir'I"Depth Si to Number SUMPS LI Distance to nearest: Well Q Foundation Property Line DISPOSAL PONDS ❑ I 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 I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature certifies the following: "1 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 call i It required inspection Complete drawing on reverse side. Signed Title: �� 4 tt cN o� Date: L1-47-90' FOR DEPARTM DEPART=MT ONLY Application Accepted by ate Area i Pit or Grout Inspection by Date Final Inspection by Date l3 v S D fie. Additional Comments: (A - Applicant — Return all copies to: San Joaquin County Public Health X75 ` 11A IXg rm1 Services, Environmental Health Permit/Services 1601 Z—Hazelton Ave., P^ 2009, Stockton, CA 95201 ��s FEE AMOUNT DUE AMOUNT REMITTED REC ED BY DATE f ERMl7 N0. INF /'�f� ro ASH + EH 13.24 IREV. n 5f 4'=f 1 ! ___LLL qq I EH A-211A-211 '