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��,/ APPLICATION FOR PERMIT- SAA JOAQUIN COUNTY PUBLIC HEALTh'*44ERVICES P ENVIRONMENTAL HEALTH DIVISION r � 1601• E. HAZELTON AVE. , PHONE (209)468-3420 CZE P Q BOX 2009, STOCKTON, CA 95201 /" 1 D sA,�• n. s <P."'t TT 2M MIRES I YEAR FROM DATE ISSI ,PU�'t;C N Ulty C. (Complete in Triplicate) �Ra,1►h; N qLLr'r;Z, fry Application is hereby made to San Joaquin County for a permit to construct and/or install the work hereindes � f/, s pplication is made in cmwliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations oto Joaquin County Public Health Services. L_ 1 Job Address rfvut it-X H5.. 300 Al. G4r+r,,de Ave City s'yCkfcNy- Lot Size/Acreage Owner's Name Sfockl., �^'�� '��Address 1 X32 Al. c' p�^`tl Dt t°e Phone —407 wq „Q ��-,I�a P.o. a&K 7zb Contractor Address G.�r,cn(�, C A 9$G�l$ License No.376 3�5 Phe gw)�4S-93SS TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O 5071 &'"f OTHER X Monitoring well (3 DISTANCE TO NEAREST: SEPTIC TANK �,., � SEWER LINES DISPOSAL FLD. PROP. LINE 122-44%;FOUNDATION _/b ft AGRICULTURE WELL OTHER WELL 29A_4S PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom O Manteca Dia. of_VM Excavation Dia. of WeIrCasing n Domestic/Private O Gravel Pack O Tracy Type of Casl�g Specifications ('I Public 1:1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation wid some: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal P� Distance to nearest: Well Foundation Property Line �(}� LEACHING LINE O No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 Perim in such manner as to became subject to workman's comPensation laws of California."Contractor's hiring or 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 all required tions. Complete drawing on reverse side. Signed X OWNER/PROJECT COORDIN'R Date: 7/10/91 ?,AFIEPAR USE ONLY Application Accepted by �` Date _/_� Area_'�_33 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 & Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. . EM ns z.11nEv.,,sa 9 e 63 ■/r� / /8