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APPLICATION FOR PERMIT (D 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 FROM DATE S (Complete in Triplicate) .2-0g--52o_0 f Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San Joaquin Count Public Health Services. oaq Y =- rfQV�r �,�/, �I Job Address r ^� h4 City A b[llPc. Lot Size/Acreage D Address Phone 8 Owner's Name {+ f Contractor r Addr ss dr J • ` Za�= License No. F Phone 21 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT L1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTAL_ATiO ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ ([� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINEr�. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS err INTENDED USE TYPE OF WELL PR BLEM AREA CONSTRUCTION SPECIFICATIO l l C7 Industrial ❑ pen Bottom Manteca Dia. of Well Excavation Dia. of Well Caein C1 Domestic/Private ravel Pack ❑ Tracy Type al Casing_ -� /Specifications A �1Y/Public /I.1'Oth�r C1 Delta *Depth of Grout Seat �E? tz?_ _Type of Grout I I Irrigation 'f Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION l I lNo septic system permitted if public sewer is available within 200 fael.l Installation will serve: Residence— Commercial— Other fi Number of living units: Number of bedrooms Character of sod to a depth of$feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line length/size LEACHING LINE Cl Na. b Length of lines Total len g FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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, state 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, 1 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 following: 1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicantII for 1 requi apsctions. Comple drawing on r erre side. sIgmm m r_7 Title: Date: 1-7-2 2 1 O DEPARTMENT USE ONLY 1 ! Application Accepted by �►. �Ila :Final - Date Area d L Pit rout spection by Date spection b Dats Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services I 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CKS J RECEIVED BY ATE PERMIT'NO. INFO a EH 1120 IrtEv. /r 5! rS EH 14-30