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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468=3420 P O BOX 2009, STOCKTON, CA 95201 j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This f application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San j Joaquin County Public Health Serv`icces. Job Address 14 7 3 7 A 2)o I2 "M cityf n fh,,7�n Lot Size/Acreage Owner's Nami oan,i.e ruzman Address _A0Ma Phone 1 Contractor Ciank Vett, Inc Address 2024 E. Chug e2_ License No.37956U Phone 46Z-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONxIk Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well O 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 n Industrial O Open Bottom O Manteca Dia. of Well Excavation. Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— Specifications l'I Public Cl Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface,Seal Installed by \�• Repair Work Done U Type of Pump H.P. State Work Done_ v ; Well Destruction O Well Diameter _6 Sealing Material & Depth e C 17? :�o Depth 102 Filler Material & Depth 6 ,3 a ck 's mad R r v-m v n i 4 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve` Residence_ Commercial e Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line 3 LEACHING LINE 0 No.,& Length of lines Total length/size FILTER BED O Distance-to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation— Property Line DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will be doom in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Jquin County Home owner or licensed agent's si mature cenifies 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 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- tion laws of California." l The applicant t II f re r i pectio Complete drawing on reverse side. VP Cia2k GJeCL, ,Inc. 22 auiy 92 Signed X Title: Date: A OR QFPARTMENT.USE ONLY Application Accepted by fib„^ Date '- rsa O Pit or Grout Inspection by Date Final Inspection by Date � Additional Comments: Applicant - Return all copies to: .. San Joaquin Canty Public Health Services Environmental alth Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA- 95201 CK INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI- NO. . EMI 3.21(REV.t/M5)W3/ EH 11.2e