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s � F APPLICATION 3 PUBLIC HEALTH SERVICES SAN - 'AQUIN COUNTY PUBLIC 04�51EAI.THDIVISION ENVIRONMENTAL HEALTH DU -1601 yT PET ' -IT =1601 E. HAZfiLTON ;}1VE: , PHONE (>� 90L RM P O BOX 2009y :.STOC%TON, CA 95201 b . sr< PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) - r 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. r Job Address _ !�'S �A. (A ri3Or-, r City�•MCiCQM. Lot Size/Acreage Owner's Name k-wir r�� Tom- D C-Z') Lf- _ Address o�.S A�n. (.ilr��,Dr\ Phone I+. - (Ze.cJ.o lbrdoV4 ConlractorL�JCS; I>c� dl Address3a�3 Fi—Z�c, Id Kd ? License No. J Phone( 6 635-7 76 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION O Out of Service Well ❑ " PUMP INSTALLATION O SYSTEM REPAIR O OTHER 0� DISTANCE 10 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLD. PROP. LINE SDIL FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS W5, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /nom/p ' n-d_ Dia. of Well Casing �r Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Sc-L,a d..fo '}n Specifications I'I Public I:7 Other z fl Delta Depth of Grout Seal 5%r Type of GroutAre�c a—A- j .,. I I Irrigation 70'Approx. Depth I I Eastern Surface Seul Installed by (A-'e 2�^ . nr W,.... L. Repair Work bone U Type of Pump H. State Work Done_ F Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I,_ DESTRUCTION I I (No septic system permitted if public sewer a NumInstaber will some: Residence_ Commercial_ Other ENVIRONMENTAL HEALTH DIVISION SAN JOAQ@fWftVN QVftl.IC HEALTH SERVI Numbeer off living units: _ Number of bedrooms - � lPa�s�epP Character o1 soil to a depth of 3 feet: . r SEPTIC TANK. ❑ Type/Mfg `Capacity—. No. Compartments PKG. TREATMENT PLT.❑ 'I Method of Disposal Distance to nearest: Well Foundation F Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ P - I hereby certify that 1 have prepared this application and that the work will beedone in accordance with San Joaquin county ordinances, state laws, and b rules and regulations of the San Joaquin County I] t j 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 t 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 compensa i tion laws of California." r - The applicant ust call for all required inspections. Complete drawing on reverse side. I ' Signed Title: 1�[.p�pc/CSJ Date: FOR DEPARTMENT USE ONLY r I j } f Application Accepted by "Date Area Pit or Grout Inspection by Data v :.Final Inspection by r _Additional Comments. 'a• 4gA Applicant - Return all copies to: San Joaquin County Public Health p Services, Environmental Health Permit/Services t 1601 E. Hazelton Ave.; P 0 Box 2009, Stockton, CA; 95201` FEE If INFO AMOUNT DUE AMOUNNy�T RR]fEMITTED CASH' RECEIVED BY 9 DATE q �-✓�PfERRMMnr'NOO.. . EN,li.[REV.IIASl y - U 1 ' 1293 //,m • !� 4 r/` 1 `' V •• FN:1-a5 I