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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 _ P O BOX 2009, STOCKTON, CA 95201 FPERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County' .._. ,.__:......._.:_s.. .. ._ _ Job Address 6'855 W. Eight Mile_ Road CityStocicton Lot Size/Acreage Owner's Nams U.S. Sprint Address Phone )967-3055 + MO 64114 Contractor�WFSTFX Addressp.n 1r 131ax 7GGW. Sar_ License No. rg�#552198Phonc�gl6)373-111 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1_l DESTRUCTION ❑ out of Service Well ❑ Moi toring well PUMP INSTALLATION ❑ 1 SYSTEM REPAIR ❑ OTHER 4C Soil Borings 13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE , ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE �yTXPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ dustrial pan Bottom Cl Manteca r Dia, of Well Excavation tO Dia, of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 10A _ __ _ Specifications 'l Public is Other 1-1 Delta Depth of Grout Seat N LA •• t Type of Grout rement 'F II Irrigation ' -atApprox. Depth I 1 Eastern Surface Seat installed by Repair Work Done U Type of Pump H.P. State Work Done S D ,,.WSealing Destruction ❑ Well Diameter � Material & Depth f � 4-5 t0 full dept Depth Filler Material 6 Depth - TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAfR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) 7 Installation will serve: Residence_` ' Commercial Other 1 r } Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: : i ) Water table depth SEPTIC TANK" ❑ Type/Mfg Capacity No. Compartments • PKG. TREATMENT PLT. ❑ i • it f. Method of Disposal r" - Distance to nearest:,P Well Foundation Property Line t r LEACHING LINE 0 No. & Length of lines+ � �_ Total length/size " 1. FILTER BED Cl Distance to nearest: Well I Foundation Property Line SEEPAGE PITS 11 Depth 1 0- Si:e xT Number SUMPS Ll Distapce to nearest� Well f Foundation Property Line1 DISPOSAL PONDS ❑ I hereby certify that I have prepared this application 0 n that the work will be done in accordance with San Joaquin county ordinances, state laws, and'. rules and regulations of the San Joaquin County'f_ t Home owner or licensed agent's signature certifies the following: "t 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 su contracting signature > certifies the following: "I Certify that in the performance of the work for which this permit is issued, I shall employ sons sublet work man'seompensa- tion laws of California." The applicant must call for all required insPections. Complete drawing on reverse side. r �✓!�� Signed Title. c2sJL - �ti1J. ' ate: �� FOR DE ARTMENT USE ONLY Application Accepted by Data 12 Area 3� Pit or Gro t Inspection by ft7 Date 1 4 Final Inspection by Date�a Additional Commenta: z Applicant - Return all copies to: San Joaquin County Public Health 4 Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. ! a Eti13.21 IREV.I/.N 51 EH:4.28