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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXP RES 1 YEAR FROM DAIE ISED (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 1 9K E. Ra-9/2h 4ye -- City S kn Lot Size/Acreage 9 Owner's Name Neea2.io De-9.ima Address 1903 E. Ralph Ave — Ph,,, 982-4410 Contractor Uank NP—Le, Inc. Address2024 E. Chaz e/c 0tC License No. 379560 Ptione462--7676_ __ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTS DESTRUCTION D Out of Service Well D PUMP INSTALLATION ADC SYSTEM REPAIR ❑ OTHER D Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK f 5 0 ___ SEWER LINES DISPOSAL FLD. *5 C]_'_- PROP. LINE _LDL'. FOUNDATION AGRICULTURE WELL OTHER WELL._ PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12" Dia. of Well Casing n x"Domestic/Private x® Gravel Pack ❑ Tracy Type of Casing. Si d2v-f Specifications-,4-Z.0L---.-- i'1 Public EI Other f-1 Delta Depth of Grout Seal 100 Type of Grout 9 hack i I Irrigation --_..Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump Su9 H.P. 1 State Work Done —mnl)D Well Destruction ❑ Well Diameter 611 Sealing Material & Depth 900' n 4 6 1 o.m 10 -tpl Depth _ 100 ' Filler Material & Depth ni TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I fNo septic system permitted if public sewer is available within 200 feet.l 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. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size — Number SUMPS UI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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: "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." The applicant M41 Joll for re ed i to pl ra ing on reverse side. Signed X ide:y/'- CPa�rk lJe�iInc Date: 29 7u�«1 __-- DEPARTMENT USE ONLY Application A copied by Date -7' _ Area ,C "3 I -� S /3 Pit=mania pection by Dat Final !ns tion by Date ,L Ad : Applicant - Return all copies to: San Joaquin Countyblit Health VAL c Services, Fnvironm tal Health Permit/Serviceslc3c- 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 i FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DAVE PERMIT'NO. INFO CASH 9/ + EH 73.24 1REV.t i K 51 w R13 �6vu EH 74-?e (r.i