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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201. tam } (209) 468-343400 t; PERMIT BMIESS 1 YEAR_VRQX RATE ISUUJM " ' f (Complete in Triplicate) f , Application Is hereby sade.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 1852 and the Rules and Regulations of Sinn Joaquin County Public Health Services. 4773 U. V o o d.I � id y e "fidcity L o d.i, Lot size/Acreage f ac z e Job Address Tony Di.niz �rLm� -4727 r 'Owner's Name Address Phone 3 b •`Contra or C-ea21LI Or-e-e Address 2024 C. Chait1g z License No.3715b __ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTf _ DESTRUCTIONxcQ-Qut of Service Well 0 PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER El Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK -1- 100' SEWER LINES - 75 ' DISPOSAL FLO, PROP. LINE t2_0 ' FOUNDATION " 'I AGRICULTURE WELL 2O OTHER WELL -12' PETS/SUMPS INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS = Ll Industrial O Open Bottom Q Manteca Dia. of Well Excavation 12a Dia. of Well Casing6" - ` xTJKDomeslic/Private Y-<7r Gravel Pack ❑ Tracy Type of CasingS t eV-e Specifications.- 7 Q A -4�PlPtsblic Il Other © Delta Depth of Grout Seal 2��)" Type of Grout 9 A a r/ ci Irrigation T Approx, Depth 0 Eastern Surface Seat Installed by C-ea zk Repair`Work Done X0 Type of PumpSutH.P. I State Work Done VNall Destruction -V0 Well Diameter." 1D R� Sealing Material & DeptheJ4C- Depth apL/? 5O Filler Material & Depth 2 M v J _ TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION G iNo septic system permitted if public sewer available within 200 fael.1 Installation will serve: Residence _ Commercial Olf er c- i v Character ofdA'to a ifepth o 3"fee Water table depth SEPTIC TANK_ ❑ Typo/Mfg Capacity No. Compartments G. - PKG. TREATMENT PLT. C1 ,: - " —Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines _ ` Total length/sire }" FILTER BED 0 Distance to nearest: "Well Foundation Property Line SEEPAGE PITS 11 Depth "_Sire Number SUMPS Ll Distanca 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 Josquin County ' Home owner or licensed agent's signature certifies the following, "I certify that in the periormance 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 Caliloinia.•' Contractors hiring of sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The applicant c for e ��I_�2wp drawing on reverse side. SignedTills: fel C-Pri�zk G!e �, Inc Data: 17 Aug92 F DEPARTMENT USE ONLY t" �� i� Application Accepted by Date {�.. A_rea ` Pit or A Inspection by T� I�0 "1 A Y Date '� `f�inal Inspection by �J�-/� Date 8-2-7-92- Additional ^a-7 - Z.Additional Comments: +Y Z ^1, /_ 1 !t Applicant - Return all copies to:- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES M t'tG�L Czl� j ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES• WtX 8 i �t` JK .,445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 C) t� ewtQ S r.INFO AMOUNT DUE AMOUNT REMITTED CASH RECEwEO By DATE f5qz - tk ?31), l� g 7 . EH1'. fREV.$iKs) W� i l r9� 1 �a� t47.2-- �17/