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t APPLICATION FOR PERMIT P, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION WOW 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 1 YEAR FROM DATE ISPUED (Complete in Triplicate) Application is hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This , application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San } Joaquin County Public health Services. ob Address 1640 RHODE ISLAND City Stockton Lot size/Acreage 333 N. San Joaquin, StocktAg1e 466-9051 JOHN KAPFOS 40wner's Name Address Contractor Address License No._Phone k' service ge—iiD PE OF WELL/PUM NEW WELL ❑ WELL REPLACEM T nDESTRUCTION Cl Out Monitoring Well ❑ PUMP INSTALLATION ❑ SYSTEM AIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWE DISPOSAL FLD. PROP. LINE FOUNDATION AGR CULTUR W L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C TRUCTiON SPECIFICATIONS , L1 Industrial ❑ Open Bottom ❑ Manteca is. of ell Excavation _ Dia. of Well Casing \ i. C.) Domestic/Private ❑ Gravel_P_ack _O Tracy��_ _ Type,of-C ng- Specifications 4 I'1 Public' Cl 011ier Cl Delta Depth of Grou eaI' Type of Grout ; I,l Irrigation, _Approx. Depth I I Eastern Surface Seal Installs Repair Work,Done U Type of Pump H.P. State Work Done Well Destruction-' 0 Well Diameter sealing Material & Depth •- Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION I I DESTRUCTION Mo septic system permitted if public sewer is _ l available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Numberof 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 1 1 Distance to nearest: Well Foundation Property Line LEACHING LINE LI No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line v SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina i 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"ant's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ my man in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature 11 cenifies the ollowing: "I unify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws o1 Calif rnla' The applican 11 for ail ad inspections. Complete drawing on reverse side. 8/21/92 YSigned Title: wn e r Date: FOR DEPARTMENT USE ONLY �qy I 4 V Application Ac by Date ?h Area Pit or Grout Inspection by Date Final Inspection by y Date Additional Comments: }� l Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 1 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED J CASH RECEIVED BY iDATE PERMIT'NO. INFO . r cr �A EH U-24 IREV,rieSt v�1 h Z /r l f EH t1•m