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�•�. , APPLICATION FOR PSR36IT '2 # SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESY ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 MAY & (209) 468-3447 ENVIRONMENTAL HEALTH Y ISSUSD PERMIT/SERVICES (Complete in Triplicate) I Application 1$ 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. i Job AddressQTTn 00 C1, City Lot Size/Acreage Owner's Name ) 2Lt - L S£ v ekIJS Address l:220 alm4sc;I,) !Rd Phone r Contractor LPAddress �3 License No. Phone TYPE OF WELL/PUM?. NEW WELL ❑ WELL REPLACEMENT -. DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR pL OTHER C] Monitoring Well G7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. J � 'PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 'PITSfSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (.1 Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public I) Orher ❑ Delta Depth of Grout Seal Type of Grout 1311tripation ..Approx. Depth ❑ Eastern Surface Seal Installed by /Repair Work Done U Type of PumpH.P, _ .5 �' State Work Done Weil Destruction ❑ Well Diameter .._i�� Sealing Material i Depth ..Depth _ _,3..jJ r Filler Material fi Depth 41?t-r7-YPE�OF;SEPTIC WORK; NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION Cl (No septic system permitted if public sewer is available within 200 feet,) r- 3nstaltation 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 PKG, TREATMENT PLT, ❑ - Method of Disposal Distance to nearest: Well Foundation Property Line i� LEACHING LINE 0 No. 8 Length of lines Total length/size FILTE=R BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest; Well Foundation Property Line .. DISPOSAL-PONDS -„.Q.— 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, andl. 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, 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 follow' : "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 law$0f rn 1 The applies mu all for all requRinspeption Complete drawing on rea side. Signed Title: Date: ''yy ® R DEPARTME USE ONLY Application Accepted by //f' Date �� Area Pit or Grout Inspection by Date - Final Inspection by Date' Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 495 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 FEE INFO AOJ9 �MMO�OUNT DUE AMOUNT REMITTED ,�C K,9 RECEIVED BY DATE PERMIT NO. . EH13-24tRIV.iin6, 4 /,tib (/'W SL EH A-2E