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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PIIONE (209)468-3420 RECEIVE P O BOX 2009, STOCKTON, CA 95201 APR 2 1 1993 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY (Complete in Triplicate) PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application in made in corWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulation• of San Joaquin County Public Health Services. Job Address _ �- City= Loot.SSize/AAcreage�Tf� Owner's Name MA:�E Address �_>��S(�7�T/lJ1;W/Yhone Contractor //�9dress 1_W_ _ ��fi� nse No. Phon TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION SYSTEWRIR LlOTHER ❑ MonitoringlIWellDISTANCE TO NEAREST: SEPTIC TANK I VLr Z_ _ SEWER LINES ��yDISPOSAL FLO. PROP. LINE j!:J!� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS / INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (I Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private : 14Gravel Pack [ITracy Type of Casing_ -) Specifications S' I I Public 1-1 Other f] Delta Depth of Grout Seal- Type of Grout I I Irrivalion Q Approx. Depth bl&fastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H P. State Work Done _ r*(k J Well Destruction O Well Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other l" Number of living units: __ Number of bedrooms Character of SON to a depth of 3 feet: Water table depth T , SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. III Length of lines _._ Total length/size- FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number T_ SUMPS LI Distance to nearest: Well Foundation Property Line P 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, stale 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractingr,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 compense- tion laws of Californla." The appli st f NI r i ed inspections. Complete drawing on se side. Signed X Title Date: FOR DEPARTMENT USE LY Application Accepted by Date A _ Area �f , Pit or Grou nspection by / Date p� (, Q Final Inspecltiioon� by Date IF Additional Comments: u Lt.(l lJs-<4i - Lam _i m Appllcant - Return al copies to: San Joaquin County tblic Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH # RECEIVED BY DATE PERMIT N0. • EH 17 24 111EV.t i n s, �"�� U ��'� �� 17066- EN t1 Ie U ✓