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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION A4 V 445 N SAN JOAQUIN, PHONE (209)468-3420 A� �7. P O BOX 2009, STOCKTON, CA 95201 Oe �,`�VE® ti PERMIT EU I RE S YEAR FROM D TE SA '3 D (Complete in Triplicate) EN CSO- - Nov1992 ' 1r,. I I/IRO�' hE�� - MEQ ray Application is hereby made to Sea Joaquin County for a permit to construct and/or install the cork y �. This application is made in compliance.-vIth San Joaquin County Ordinance No. 549 and 1862 and the Aulea and�t of San Joaquin County Public Health Services.Job lZoAl Job Address 1 221a a✓ r1 Le City S/ocf"/''t Lot Size/Acreage ,�-qy�S Owner's Name J2'I Scar/ �•` /SGC' Address l-2�y it de 'Phone a0F2 Contractor LZSF {. „ate �-� Address IQ cera Cor da �. �i�`rl License No. PhoneN4< 4_fr-L2-7 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION LlOut of service well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER lrj.-So"°��t�t."f` L DISTANCE 70 NEAREST: SEPTIC TANK; ,�� SEWER LINES DISPOSAL FLD. A14 PROP. LINE -f�G_-(r�e,rx�• ins FOUNDATION _ _ AGRICULTURE WELL OTHER WELL PITSISUMPS Ja iNTE DED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � L) Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing_ Specifications 1'I Public 1-1 Other ' 1-"1 Delta Depth of Grout Seal - Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump'[ H.P. State Work Done Well Destruction ` '0 'Well Diameter") Sealing Material i Depth y '� Depth I filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION i I DESTRUCTION f I lNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Numberofbedrooms Character of sod to a depth of 3 feet: ') Water table depth SEPTIC TANK.: ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ {� Method of Disposal �} Distance to, rest, Well Foundation Property Line LEACHING LINE Ll No. b Length of lines Total length/size (�l FILTER BED 0 -.Distance to,nearest: Well Foundation Property Line tltl . '1 P SEEPAGE PITS I I Depth Size Number i SUMPS Ll Distance to.nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 b6nifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not f employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature canifies the following: "I certify that in the performance of the work for which this permit is issued, i shall employ persona subject to workman's compensa- tion laws of California." The applicanLoust tccall for all required inspections. Complete drawing on reverse side. k Signed sr 'C• `r y Title: I Date FOR DEPARTMENT USE ONLY Application Accepted by Data Area Pit or Grout inspection by t Date Final Inspection by Data Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health Services - ¢� ces 445Environmental Joaquin, P 0 Box 2009, CA 95201 29 FEE5� INFO AMOUNT DUE AMOUNT AEMITTED ASH. R CEIVED BY DATE PERMIT-NO. Em. EM0-T4IItEV.tinai 89.E 89.DD 10+0 -��{•za k