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— ` APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 9.5201 (209) 468-3447 'f pEgUIT E%PIRHS I YEAR rRON PATE 15SUIM (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 coupliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 29929' S . CHRISMAN RD. City TRACY Lot Size/Acreage 1 ACRE Owner's Name RICHARD T. MAYERS Address 29573 S. CHRISMAN RD. Phone 909¢835-624 1 Contractor SAME Address SAME License No. NSA Phone SAME � TYPE OF WELL/PUMP. NEW WELLXX WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 1 PUMP INSTALLATION SYSTEM REPAIR Cl OTHER ElMonitoring Well O - DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 2.I]L FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 611 0Industrial C3 Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing (_kDomeatic/Private (A Gravel Pack CX Tracy Type of Casing PT,AqTTr Specifications - p M Public ('1 Other 00,1 Is Depth of Grout Seal Type of Grout G lrriUation 1 0 Qkpprox. Depth d Eastern Surface Seal Installed by OWNER :Repair Work Done v Type of Pump Sub H.P. 1 1 �2 State Work Done INSTALLED N Wail Destruction ❑ Well Diameter 6.11 Sealing Material i Depth Depth 1 7 5 Filler Material i Depth available TYPE OF SEPTIC WORK: NEW INSTALLATION L7 REPAIR/ADDITION C1 DESTRUCTION G ble system permitted it public sewer is avawithin 200 feet.i Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of eoii to a depth of 3 feet: Water table depth r SEPTIC TANK 0 Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line �l `ice `J• LEACHING LINE LI No. & Length of lines - _ Total length/size r - o - FILTER BED CI Distance to near0%T. ` Well Foundation ¢ - Property Line SEEPAGE PITS 11 Depth Sixe Number SUMPS LI 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 cenifi 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 workrran'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." Theapplicant,mos -calk for 11 requ' ed inspections. Complete drawing on reverse side: ""� 1 /27/91 OWNER Date: Signed Title: F6R QEPARTMENT USE ONLY ApplicstroAccepted by y ,r T Data k? �/4 Area al� Pit or Grout Inspection by Date Final Inspection by 14 Date : Additional Comments: Applicant,,-Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES r 445 N SAN JOAQUIN, P 0 BOX 2009, STUCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 6Y DATE PERMIT'NO. INFO . EM 17.24 tFIEV.itm6! -0 EH 14.26 I