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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P. 0 BOX 20091 STOCKTON, CA 95201 PERMIT EXPIRES I 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. Job Address 15405 Lo cu,6 7aee Rd Cityf_od Z Lot Size/Acreage -45- a r-alfa 4 Owner's Name /'en "r/oeh z i-ng Address flame _ Phone 333-0531 Contractor C e¢n k Og L.e, Inc Address 2024 E. Cha,zte z License No. 377560 Phone 4 62-Z6ZL._ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTIONJtT of Service well ❑ PUMP INSTALLATION C] SYSTEM REPAIR C1 OTHER ❑ Monitoring well C7 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 n industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications I'! Public 1.1 Other n Delta Depth of Grout Seal Type of Grout 1 I Irrigation _Approx. Depth I I Eastern Surface Sedi installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth 41.-0-f 0 n I f n m f a 4.Qp 6 ,S a c Depth 100 Filler Material & Depth 6and S cennen;� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR IADDITION I 1 DESTRUCTION I 1 INo septic system permitted it 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 n 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, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies 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 applican all f a e s c" ns. a late drawing on reverse side. Signed X Title: VP Cic�z.k _d-e te, Inc _ Date..6 jane 1992 F R DEPARTMENT USE ONLY 1(f Application Accepted by Date — ��r ! Area d 1 - i Pit or Grout Inspection by Date Final Inspection by Date '"''�` Additional Comments: _ T _ �) Q& Applicant - Return all copies to: San Joaquin County Public Health Services �s9� �+•!z- f, �� Environmental Health Permit/Services v 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE r INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. /�q . EH 13444(REV.1, 5) 4 EH 14.25 "�