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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 PO BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1, V •;,(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. Job Address 4005 N. PEZZI LANE City LINDFN_ __ Lot Size/Acreage Owner's Name DICK SEEKATZ Address 14171 E_ EIGHT MTLF_ RD_ LI.14@89 ContractorPURVIANCE DRILLERS�dNCI, P.0.BOX 64,LINDEN License No, 377923 Phone 887— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION X] Out of Service Well ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing -L 'I:) Domestic/Private ❑ Gravel Pack El Tracy Type of Casing_ Specifications Q Il Public i-1 Other hl Delta Depth of Grout Seal Type of Grout Q I I Irrigation —Approx. Depth l I Eastern Surface Seiil Installed by III Repair Work Done U Type of Pump H,P. State Work Done _ Sealing Material & Depth ti U t ('FMFI1TT r Well Destruction A* Wel! Diameter -- •— Depth Filler Materiel & Depth SANDY LOAM 15 0 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADOITION f I DESTRUCTION-19-(No-septic system-permitted if public sewer is rn 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. 0 'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length-of lines Total length/sizer FILTER BED ❑ 'Distance to nearest. Well Foundation . Property Line R1 SEEPAGE PITS 11 Depth Sire Number SUMPS E_1 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 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: ".lcertify that in the performance of the work for which this permit is issued, I shell 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." The plicant u t call f r al eq ed inspections. Complete drawing on reverse side. Signe Title: rORU�T_ C' RRRTAR V Date:8/1.8/9 2 FOR DEPARTMENT USE ONLY a r Application Accepted by Date. —1 S lZ— Area/y Off Pit or Grout Inspection by Date Final Inspection by.��,,,t+ �-rJ Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit;/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED SH RECIFIV0 By DATE PERMIT NO. . EH 132iIREV.,/MSV Gorp� C! O � Q � /20 ✓ � EH uaa 111!!!!