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46 APPLICATION FOR PERMIT • 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 EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application In hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application to 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 1700 N. Broadway City Stockton Lot Size/Acreage - Owner's Name Ryder Truck Rental Address 1700 Broadway, Stockton Phone C ncdo680-4442 Contractor Gregg Drillinq Address 2047 Arnold Qn usr�riLa Jnse No. 485165 Pnone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER X] n tori Well ❑ SoiyLorings DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ 1/29/( 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial C1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C 1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications I'1 Public 1.1 Other n Delta Depth of Grout Seal 1 5 ' 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 _ Well Destruction O Well Diameter Sealing Material 4 Depth rl g ts*C&vNka IS Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will some: 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. B Length of lines Total length/size -- FILTER BED C) Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 applicants . Title: ont call for sell ree�quired inspections. Complete drawing on reverse side. Signed K ' �_\ Q k L V y o Date: n y t. a �-�•• �- FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by o Date �Final Inspection by Date Additional Comments: -��D 4- -�' f- Applicant - Return all copies to: an Joaqul County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 `- FEE AMOUNT DUE AMOUNT REMITTED CKREC INFO CASH IVED BY DATE PERMIT NO. • EH I3N IREV.1/x51 FH I4 M