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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 o S3 7 P O BOX 2009, STOCKTON, CA 95201 -5- 7 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED If �ePa. (Complete in Triplicate) JNO l'l/,tr -' Application is hereby cede 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. 5499 and 1862 and the Rules and Regulations of San Joaquin County //y Public Health Services. � 1' K � Job Address P9 vicHeS5ig PN / City !' Lot Size/Acreage Owner's Name Ziff itl k're Address r_arr'f Phone Contractor G .f _ Addressa 1°14 License No.73; ✓ 6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public Ll Other El Delta Depth of Grout Seal _ Type of Grout ) rngabon —Approx. De th I 2stern Surface Seal Installed by 10 ee� Repair Work Done Pf Type of Pump rC H.P. State Work Done Well Destruction ❑ Well Diameter Sealic�`ig�Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feel.) (� Installation will serve: Residence_ Commercial_ Other •.�) Number of living units: _ Number of bedrooms Character of soil to a depth of 3 lest: 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 CI No. 6 Length of lines Total length/size FILTER BED ❑ 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 I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 no 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 lollowin ' ertify 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 C trite." The applic must c or alt required i peciions. Complete drawing on rev ids. x. Signed _; OM lic Title: Tp Date: //��Q,,,,z��.E��,� M n� � _� FOR DEPARTMENT USE ONLY Application Accepted by bf l�(AA�J� Date 02 ea Pit or Grout Inspection by Date Final Inspection by Date 1 .. 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 /V FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT NO. INFO CASH . EH 1l]4IREV.rrnsr(na , r q 0 ,9 JS5 F 1'3-1 -3 -9--3 93' 1620 EH 16a)