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4bAPPLICATION FOR PERMIT 0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 PERMIT R4DTRES 1 YEAR FROM DATE ISSUED (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. Jeb Address 1700 N Broadway City Stockton Lot Size/Acreage Owner's Name Ryder Truck Rental Address 1700 Broadway Stockton Phone CRncgrd 485165 Pnone 68b4 �12 Contractor Gregg Drilling Address 2047 Arnold In us rLa4dse No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ClOTHER C R�AOo�itoring Well LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROF . gg-ngs 2/22/91 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom CI Manteca Dia. of Well Excavation Dia. of Well Casing I I Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing_ __ Specifications 1'I Public 1:1 Other ❑ Della Depth of Grout Seal 20 ' Type of Grout I I Irrigation __ Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. State Work Done_ Sealing Material & Depth 6tAAA C&d g•.t NlAtr.'t 7 r Well Destruction ❑ Well Diameter r Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is 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 ❑ 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/size FILTER BED E) Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 workmen'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 applic t call I utred inspections. Complete drawing on�reverse side. Com. Signed % ` r.�QA iIL A A Title: iV Yg66e�n Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: `"S <�/(6�tJ( w ljj.jjav� Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services (.fr / n ` 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 12 / � l FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. INFO CASH . EH 13341REV.iia 51 $178 . 00 \O'"t61 • • 233 EH 1419