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APPLICATION FOR PERMIT ! SAN JOAQUIN COUNYI']t PiTBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 R ITEXP RES 1 IBAR FROM DATE 11JSUED (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 Bab Joaquin County Ordinance No. 5h9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address " ' RIJAI City --gTtlCKT _ Lot Size/Acreage Owner's Name ' Address Phone i Contraclor WOACK PLMIP LOMPANY Address ' License No.0 _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ i PUMP INSTALLATION ckx SYSTEM REPAIR ❑ OTHER ❑ Monitoring Veli [7 DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FILO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i a F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing Specifications Public 1:1 Other fl Delta Depth of Grout Seal Type of Grout i I ! Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by ; Repair Work Done 12 Type of Pump -94W4fi4W8LLH-P. State Work Dori@ _11J31AI 1, 111WUSTOLF Wall Destruction ❑ Well Diameiei Sealing Material ti Depth _ _ trtauP_tri :Ir�� urf l Depth Filler Material t Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is ..,. available Within 200 feet.) Installation will serve: 969idence— 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 0 No. b Length of lines Total length/iiia FILTER BED n Distance to neire t: Well Foundation Property Line SEEPAGE PITS i I 'Depth Size Number SUMPS LI Distance to neatest: Well Foundation Property Line DISPOSAL PONDS, ❑ I hereby certify that I have prepared this appficailon 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 ceiiifies 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 i certifies the following: "I certify that in the parformanci of the work for which this permit is issued, I shall em to tion laws of CelifornN." P Y Pe►sons subject to workman's eampensa- The applicant muss call for al req fired iytt s C drawing oil fevers@ side, Signed Title: . RETAIL SALES Date: i , F DEPARTMENT USE ONLY Fv. y� Ct V Application Accepted by �_ ►t.sA--"� : Cy;, ,`J��:�.ty��'�".�t.�., Date Area Pit or Grout Inspection by Data Final Inspection by Date ll Additional Comments: Fij Appileant — Return all copies to: San Joaquin County Public Health Services, Mavironment:al Health Permit/Services 1601 L�. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 t FEE AMOUNT DUEAMOUNT REMITTED CK INFO CASH RECEIVED BY /DATE) PERMITNO. n9� f . EHI)-21[REv.tis� f�' fu ;) 91u—2 � I k � EH 71-2E I