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' ►� i �� +- APPLICATION FOR PSRHIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009 , STOCKTON, CA 95201 PERMIT EXPIRES I YEAR-ERQM D TE (Complete in Triplicate) APP11cation is hereby Sade to San Joaquin County for a permit to construct and/or install the vork herein described This application !a Stade in compliance vith San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address T kor N i0✓► City 54Cl1r-Lt0t^ Lot Sim/Acreage 0. 6 A Cre r .Sou lnla-.� 560?p Owner s Name — D r Address 1'1�p�( �� 3+17 Phone Contractor Kvt Wel 1111ddressMCl < <r'` License Ho Z3qO Phane5iR TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ® rn � Wel te1�irr� ❑ DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom 0 Manteca Dia of Well Excavation S 41Du of Well Casing •e n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications pecifications ' i I Public n Other fl Delta Depth of Grout Seat 1' 4 Type of Grout -"t I Irrigation Approx Depth I I Eastern Surface Saul Installed by JK v� kk 0yttli" Repair Work Done U Type of Pump H P State Work Dana-_ I Well Destruction 13 Well Diameter Sealing Ilaterial i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet I raltation will serve Residence _ Commercial_ Other W-mbar of Irving 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 O Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE Cl No 5 Length of lines Total length/lire FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances stale laws, and 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 subcontracting signature certifies the following "I certify that in the performance of the work for which this perrnit is issued, 1 shall employ persons subject to workman s compense tion laws of Califomia" The appi"rit must cap for ail required inspections Complete drawing on reverse side / Signed Title �� Data ZO 2-17f FOR DEPARTMENT USE ONLY if Application Accepted by Data Area Pit or Grout Inapection by Date Final Inspection by Oate tional Comments Applicant - Return ail copies to San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 9009, Stkh, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED NY DATE PERMIT NO 124 rR(v 4<K