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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i " "�'� .E, ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE, , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 1 PERMIT EXPIRES 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 maden compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Publi Health Services. Lot O/ /Reco zd Job Address 8 6 3 9 G1 a eau.t A cILP 6 City St kn Lot Size/Acreage 1 a CILe Caherza>Je 8639 Uaiau.t ,esus Phone 931-4924 Owner's Name Address Phone Contractor C-ea zk Inc Address 2024 E. ChaitLQ-it Lao License Ni-71 J60 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTA:Vax DESTRUCTION lliput of Service Well ❑ PUMP INSTALLATION-VC SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES DISPOSAL FLD. PROP. LINEI_;..' FOUNDATION AGRICULTURE WELL OTHER WELL-11-L— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I,"' Dia. of Well Casing XK-Domestic/Private x-PJC#avel Pack ❑ Tracy Type of Casing Specifications . n I"I Public is Other n Delta Depth of Grout Seal 100 Type of Grout 0 6a C� V�b i I Irrigation —Approx. Depth I i Eastern Surface Seal Installed by UrIaL Repair Work Done 0 Type of Pump Sud H,P. ^ 3 State Work Done-in,6 JCS;,19 Well Destruction Ocx Welt Diameter Sealing Material & Depth 7 0 n f Depth Filler Material b Depth 9 A cL a TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I tNo septic system permitted if public sewer is available within 200 feet.1 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 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Sire _ Number SUMPS Ll 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 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." Contractors(tiring or sub-contracting signature certifies the following: ' certify he rfo►man a of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of Calif m1a,' The applica all f r a qui s ins on Com lets drawing on reverse side. Signed Title: V1 C. a zk Vei_f, Inc Date: 19 au r?ra „91 DEPARTMENT USE ONLY q { Applicati Accepted by r1 Date ` y�� y Area Pit orUOU spection by - Date Final Inspection by Date i Additional Comments: fA Applicant - Return all copies to: San Joaquin County Pu lic Health t�1 r�I`1~� pQj/ Services, Environmental Health Permit/Services I `J -'d7 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE e. INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT N0. W N q . EH 1324018V.1/451 ' 3�fO� r ` �'_ EH 14.2t1 11 L