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✓) APPLICATION FOR PERMIT ('1� S JOAQUIN COUNTY PUBLIC HEALTH SERVICES f ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZRLTON AVE. , PHONE (209)46$--3420 f P O BOX 2009, STOCKTON, CA 95201 REAMIT EXPIRES 1 YEAR FROM D T ED l (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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. '�_ �tzl v> tl lie �0&4 ra �3 Job Address ____.— .__._ S�� Lot Size/Acreage Q SO u ted -I Owner's Name +9 i0 -i Dr �14acx�6,-, .A 58 3 5 Address _�,. �yPnona d� �3 n � r c ar, Address_ _ _ � L i c e n s. a. 3 P ` TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ li PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL . ,., OTHER WELL_____ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �] Industrial ❑ Open Bottom ��❑,,,sss Manteca Dia. of Wait Exc ation r Dia. of Welt Casing 6 C] Domestic/Private ❑ Gravel Pack 1c Tracy Type of Casing Specifications l'I Public ISO her n Delta Depth of Grout Seal 0_3 3Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by C Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material t: Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDtTION I I DESTRUCTION I I iNo septic system permitted if public sower is I available within 200 feet.) 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. ❑ TypelMfg Capacity--- No. Compartments PKG. TREATMENT PLT. ❑ PMMG*T Distance to nearest: Well Foundation Prope1qEhn.1T1X&1!!.M!%_ LEACHING LINE Cl No. & Length of lines Total length/11i FILTER BED ❑ Distance to nearest: WeII Foundation p OAtQUW t-flfINIY PUBLIC HEALTH SERVICES SEEPAGE PITS i t Depth Size N.WglRQNMENTAL HEALTH DIVISION SUMPS Ll 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 San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County x 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." Contractors hiring or sub-contracting 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 convensa- tion laws of California." The applicant must call f r all rycluired inspections. Complete drawing on reverse side. ' } � Signed Title: Oat , OR DEPARTMENT USE ONLY "'Date Area h 21.oa Application Accepted by ' Pit or Grout Inspection-by �{ � Date Final inspection by Date setAdditional Comments: b �`+� o f V'I h i 1 ETED � Applicant - Return all copies to: San Joaquin County Public Health �„_ � Services, Environmental Health Permit/Services W�KVA 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DE: HM INFO Q�CASH . EH 17d4[REV.rir .�� .�l• " V ��"" �, �• EH;1.26