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1 �F APPLICATION FOR PERMIT ,� SAN QUIN COUNTY PUBLIC HEALTH , VICES ENVIROMWENTAL HEALTH DIVISION PAYMENT 445 N SAN JOAQIIIN, PHONE (209)468-3420 RECEIVED P O BOX 2009, STOCKTON, CA 95201 F E R 0 1 1993 } PEMIT E%PIRES YE ROM D TE.; SII SAN JQAQU,,,,j C,0,!itiTY i (Complete in Triplicate) I PUBLIC HEALTH =eRvf�'cS Application is hereby made to San Joaquin County for 1 ENVIRONMENTAL gEAr T�I vfS !a application is made is compliance with San J y permit to construct and/or install the work herein escr Joaquin Count Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin iouaty Public Health servcompliance wis. i j Job Addrasa l City S I Lot Slze/Acreage Owner's Name Address C'i Phone +T r F W .� t55�i t�Cantractor AddressLicense No.5��Phone . 1 W� Li3 r TYPE OF WELL/PUMP NEW-WELL r� WELL REPLACEMENT l-1 i 5f DESTRUCTION ❑ Out of Service Well C1 PUMP INSTALLATI N ❑ SYSTEM REPAIR ❑ '� OTHER p Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES 7 f _- DISPOSAL FLOW4- PROP. LINE LSA f FOUNDATION AGRICULTURE WELL DTHER WELLS _PITS/SUMPS_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excava�tio�n Dia. of Well Casing 0 Cl Domestic/Private ❑ Gravel Pack C3 Tracy Type of Casing_YV, - Public n Other Specifications -•-- - Delta Depth of Grout Seal f`I ��- '�, Type a! Grout__17�f-�f=tlYo I i Irrivation �Approx. Depth I I Eastern Surface Seal Instailed Repair Work Done 0 Type of Pump H,P. 1 Stats Work Done� } Well Destruction ❑ Well Diameter Sealing Material ! Depth !� Depth Filler Material i Depth JI I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is adyailabls within 200 feet.) , Installation will serve: Residence_ CommOther j Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity I No. Compartments PKG. TREATMENT PLT.❑ 'a � Method of Disposal i Distance to nearest: Well Foundation I Property Line ; r LEACHING LINE ❑ Na. 3 Length of linesTotal length/sire FILTER 13ED ❑ Distance to nearest: Well Foundation I� Property Line I� SEEPAGE PITS I l Depth Sire Number .+ ' SUMPS LI Distance to nearest: Well Foundation II Property Line DISPOSAL PONDS [I �� G I I heroby certify that I have prepared this application and that the work will be done in accordance with,!Son Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin county } Home owner or licensed agent's I� eW sgnature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any parson in such manner as to become subject to workman's compensation laws of California.''Contractor's hiring or sub-contracting signstuse certifies the following: "I certify that in the performance of the work for which this permit is issuaif,I shall.employ persons subject to workman's compensa- tion laws of California.- The applicant murA call for all reqs'ed inspeclions. Complete drawing on reverse side. Signed Title.• r,�'Il„ Dale: F DEPARTMENT USE ONLY Applkstion Accepted by �.(7, Z Z I Date Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: I M Applicant - Return 911 copies to: San Joaquin County Public Health Services Environmental Health Permit/Services i 445 N San Joaquin, P 0 Boa 2009, Stkn, CA 95201 ,I ,k EEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO T1TT �x+9 T1771� CASH Fey RECEIVED DATES PERM17,No. . EH 14. IItEY.nisei $q- CJV CJ L ,I JCJ 24t J 1 / / ! �. i +✓ +��0�. FH 1�•7a !!