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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 i P O BOX 2009, STOCKTON, CA 95201 it r1TT1fTR� EgpIRES 1 YEAR FRAM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. L (�b �'QG �1� �L�C City " A Lot size/Acreage Job Address Phoney Inv - F',A, Address P ung =,� � ' Owner's Name _ 7t ��v� License No. Phoney en Contractor } oat ' e�i' a`-Address - _--- — TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT C� DESTRUCTION ❑ Out of Barring Well OTHER ❑ Monitoring Well [j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ —�-DISPDSAL--FLD. - -PROP. LINE,/--- DISTANCE INE, ^"""� DISTANCE TO NEAREST:-SEPTIC 7ANK� --- SEWER LINES�^_ PITS/SUMPS f:OUNDATION -- AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA rt"CONSTRUCTION:,5PEGIFIGAT IONS=x W3 Dia. of�Well Casing E� Industrial ❑ Open Bottom _-.._--0 Manteca Dia. of Welt Excavation III „o- T `e of Casing ° ` 4 Specifications_ C:] Domestic/Private ❑ Gravel Pack' C7 Tracy �;� �.Yp nw,_� .� +s �-o - Type of°Grout I:1 Other : 6 Delta Depth of Grout-Se`al�" 1'1 Public : k ! I Irr -___.. igation Approx. Depth 111 H.Eastern Surface Soul Installed by � r � 1 State Work Done Repair Work Done ❑ Type of Pump., ' Well Destruction ❑ well.Diameter T�— '^ Sealing-Material--&-Depths -�--c- - ti Filler Material & Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION`i DESTRUCTION t I (No'Isseble ptti Hs stem i�smitled it public sewer is avithin 200+ r F tJ Installation will serve: ResidenceJk'Commercial=�Other Number of living units: Number of bedrooms--2, Character of soil to a depth of 3 feet: Water table depth ' r SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments 2. PKG. TREATMENT PLT. Method of Disposal Ll 6 Distance to nearest: Well Foundation Property Line 3 : LEACHING LINE b 'No. & LTotal length/size ength of lines r FILTER BED 0 Distance to nearest: Well Foundation Property Lina s `4 Number 1 _ 4's ._Sire� � SEEPAGE PITS '0 11 Depth i , SUMPS f y Distance to nearest: Well. S� Foundation Property Line DISPOSAL PONDS C) will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance rof n the work fct which this permit is issued; I shall not a s of California." Contractor's hiring or sub contracting signature employ any person in such manner as to become subject to workman's compensation law certifies the following: "I certify-tha117n the-performance_of.the work for..which-this-permit-is-issued,-I_shall employ-persons subject tow orkman's'ompensa- tion laws of California." [ i The applicant"ford inspections. Complete drawing on reverse side. Signed X Title: Date:` F EPARTMENT USE ONLY # Date ?i Ate`' rail ApplicationAccpy - r �:s �. � % Pit or Grout Inspection by Data Final In�sp an b; l f Id46 ! ' JAdditional Comments: Applicant - Return all copi-_i+o: San Joaquin County Public Healtht` --�. Services, Environmental Health Permit/Services„ # 1601 E. Hazelton Ave., P O Box-2009, Stockton ,.CA 95201- FEE A OUNT Ot1E [IZED KRECEIVED BY DATE PERMITNO. INFOASH EH r3-24 1REV,1/A S] EH 14.26