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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES : 3� ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EMIRES 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 7862 ZL� (7oi.-eeand City Cfkn _ Lot Size/Acreage L94 074 d Owner's Name Ri ft on Pe-6k-in Address 1 rnv Phone 4 7 R7 R Contractor C.Pa)zk 0,e P1 Address 2024 E. Cha2i•eq- E_ic nse No.37 Phone TYPE OF WELL/PUMP: NEW WE WELL REPLACEMENDESTRUCTI of Service Well D PUMP IN!'TALLATIE)SEWER SYSTEM REPAIR 07 Monitoring Well L7 DISTANCE 70 NEAREST: SEPTIC TANK -A 7 LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL r ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial ❑ Open Bottom ❑ Manteca Dis. of Well Excavation 4 N r Dia, of Well Casing y xhE:-Ypomestic/Private xM-Ztravel Pack ❑ Tracy Type of Casing_ P VC Specifications Lf- I'l Public I:1 Ojhf1 Delta Depth of Grout Seal 900 Type of Grout 9 Ar, k I I Irrigation e��AtplpSrIoxx.. Depth I I Eastern Surface Seal Installed by rY 0/7 k Repair Work pone LJ Type of Pump SUP- H.P. 7 912 State Work Done Well Destruction ❑ Well Diameter 6 n Sealing Material & Depth 4 444 4 64i�e irt9 �a C k Depth a,2,9 10 0 ' Filler Material & Depth { TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION l 11No septic system permitted if public'se4er is available within 200 feet.l 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.0 Method of Disposal A Distance to nearest: Well Foundation Property Line !4J LEACHING LINE C1 No. & 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 ❑ f 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, J 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' comp ns r tion laws of California." �+ �4 -716 /if) / e I d ($s The applicant st 11 f r a oins ctions.fo4ete drawing on reverse side. /s 0 Signed Title:VP- Date: FOR DEPARTMENT SE ONLY L°r�f vr�I ~..Cwi�17x Application Accepted by M r%r.% 7 XV- Date_..._ r !-fes Area L q Pit or Grout Inspection by ate Fi al Inspection by Date ^� 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERM11'NO. 8 We . EHi3.741REV.r,nS> [fe 9 Q �t 1�� 603L( ¢Zq�_ �A 9 EH 14-Ie 'i JL 1 V `7 ��*�