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APPLICATION„F'OR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 r P 0 BOX 2009, STOCKTON, CA 95201 II I PENIT EXPIRES 1 YEAR FROM DATE ED. (Complete in Triplicate) • I Application is hereby made to Sen 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. II Jab address 13251 E. EIGHT MILE-ROAD City F` Lot Size/Acreage ii Owner's Name JACK FREEMAN Address 13251 E. 8–MILE RD,_ STKN Phone 931 -4067 Contractor NOACK PUP COMPANY Address 4500 E. FREMONT STOCKTNense No. 504513 Phone 948-8817 TYPE OF WELL/PUMP: NEW WELL ❑ %`WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well 0 PUMP INSTALLATION PX SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF.IWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing XXDomestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications H Public C] Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Sedi installed by Repair Work Dons CA Type of Pump _& SIBLEf•P — E � ISP _ State Work Done PUMP r Sealing Material & Depth, WITH-7 1 2 KP- BMERSIBLG� Well Destruction ❑ Well Diameter i i , k t.. ,IT - I — + Depth ” Filler Material & Depth* A Dt IMD TYPE OF SEPTIC WORK: NEW INSTALLATION I I t REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Instaitation-will-servet--Residence.._;,^'= Commerciai,.,=-Other-,-`-----•� �- - Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK. ❑ Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: _Well Foundation Property Line i i r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to neatesf: r Well Foundation Property Line \ { n + SEEPAGE PITS I I Depth =Size Number Il SUMPS C! 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 l 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 no 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." The appli nt ust all for II r ins tions. Complete drawing on reverse side. a ^! r a7 ! Title: RETAIL SALES 9' /` 10-9 Signed pate: Ill t �i FOR (DEPARTMENT USE ONLY Application Accepted by t Date , Area 4 �, Pit or Grout Inspection b Date Final Inspection by "ate IE .� Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health �! Services, (Environmental Health Permit/Services 1601 E. Hazelton Ave., P D Box 2009, Stockton, CA 95201 FEEAMOUNT DUE AMOUNT REMITTED C CK# ECEIVED ElDATE PERMIT*NO. INFO a E1413-24IREY.t/1151 % ZI EH:4•2a