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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION , ,1601 E. HAZELTON AVE. , PHONE (209)468-3420 P U BOX 2009, STOCKTON, CA 95201 ` EXPIRES 1 YE R FROM DA ED (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. 51r9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Serices. 1900 Navy D zive City Stkn Lot Size/Acreage Job Address 7 z 85178 rte UgcLen Cnv2 .� onme.n.fa.� Address I O Bo Pho p Owner's Name Contractor Ua2k Op-ii, I2c Address 2024 6• Chani- -',z Orly License Ko.371560 Phone�6Z-7b76 TYPE DF WELLlPUMP: .NEW WELL ❑ WELL REPLACEMENT 1-_l DESTRUCTIONS® Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ' C.1 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing f- DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I`! Public 0 Grav E " Delta Depth of Grout Seal Type of Grout j I I Irrigation ��,Apprax. Depth I I Eastern Surface Seal Installed by. Repair Work Done L7 Type of Pump H.P. State Work Done — Weil Destruction ❑ Well Diameter 1 6 a sealing Material Depth 2 12,9u� fJJO-- Depth t# � Filler Material b Depth lee Zack � -— TYPE Of SEPTIC WORK; NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I allo septic withm rented if public sewer is: vailable installation will serve: Residence '.i l Commercial _ Other. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth tCapacity No. Compartments SEPTIC TANK. ❑ Type/Mfg PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line tl SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ � , rk will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that ! have prepared this application and that the wo 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, 1 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." 1 The applicant st all f aqui do . C mplete drawing on reverse side. Signed x Title: / Uank Ve.�.� INC. Date: 24 lulu 91 -- ._ FOR DEPARTMENT USE ONLY Application Accepted b " Date Area Pit or Grout Inspection by Date Final Inspection by ata Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 fEtcMOUNT DUE AMOUNT REMITTED CAS BY DATE PERMIT'NO. INF ♦ EH 13'24(REV.W R 51 -7 -2 EH 14-26