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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ��(� p ^•/ Job Address `'TDO K/�). T'� v�ti-r Rd • City fi�>< e-Op Lot Size/Acreage !3 P Owner's Name MbA1rE i• t Q FA Address 10(5!4 •EflI S�/l�• �1�AN� rte 3 Contractor c�' Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fl Public fl Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth - r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitled if public sewer is Q available within 200 feet.l Installation will serve: Residence X_ Commercial— Other— Number ther Number of living units: �— Number ofrooms Character of axil to a depth of 3 feet: ` A7 / A41h Water table depth �. SEPTIC TANK B--Type/Mfg v,A,Jl!L 7'P_ Capacity&�' r%Af-.No. Compartments PKG. TREATMENT PLT. ❑ le 0 Method ofDisposal —tom Distance to nearest: Well Foundation S� Property Line mo LEACHING LINE [P—No. 8 Length of lines RAJ Total length/size 4 FILTER BED ❑ Distance to nearest: Well O O Foundation ?—00 Property Line SEEPAGE PITS 1 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina 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 v 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 California." The applicant must callforall require(�d�iQnn"!ctions. Complete drawing on reverse side. Signed x /M� 1�Y1� Q Title: uDCR Date: 7 - 2-7-90 �(1F DEPARTMENT USE ONLY Application Accepted by Date Odes Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 IFEE NFO if AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. . ER 3-24(REV.i/ev EH 14 20 I ,p0 ro'O 7 3L I0 QO— 91q