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APPLICATION FOR PERMIT f ) SAN JOAQUIN COUNTY 'PUBLIC HEALTH SERVICES u�• �NTAL HEALTH DIVISION IN AVE. , PHONE (209)468-3420 +. 109, STOCKTON CA 95201 . 4. 1 , UR IG 1991 S I. YEAR FROM DATE issurm ete in Triplicate) EN`:*,P. NilNii-NTALHEAL1,. Appl: Lper-mit-to construct and/or install- the Work h�irei-W` �s ??M ESThis appl: rdinance No. 549 and 1862 and the Rules and Regulations of San Joagt kJob o CityS� Lot Size/Acreage Owns i J ; Phone mac)tC • Conir u •License No.&Q, Phone TYPE jWELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service We,11 ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DIST, LINES' - DISPOSAL FLD. PROP, LINE �LTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r,dusttial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing -Z- n n Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing � � Specifications I'1 Public F Orther Cl Delta Depth of Grout Seal Type of Grout I I Irrigation 00�.Approx, Depth 11;Eastern Surface Seal Installed by V11 Repair Work Done L] Type of Pump H.P. State Work Done Well Destruction O Well-Diameter Sealing Material & Depth Depth Filler Material & Depth. TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feat.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments t1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line a LEACHING LINE ❑ No. & Length of lines Total length/size 4 I FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not 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 followi "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 Cal' rni ." The spl: can ust all for ar1re inspe, ti s. Complete drawing "verse side. �/ / Signed Title: `'�� l Date: ` ` y/ ti FOR DEPARTMENT USE ONLYZ�L L �I ` n�lr- Application Accepted.by Date � ) Area '� r Pit or Grout Inspection by '1 'Data Lr Z 9 r Final Inspection by Date Z� 1 Additional Comments; Applicant -- Return all copies to: San Joaquin County Public Health ,rt Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009., Stockton, CA 95201 CK V i. FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ATE ) PERMIT'NO. f �� I [� Q INFO �,�'D n-