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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r` ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PERMJJ EXPIRES 1 YEAR- FROM DATE_ISSU.M (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This s application is made in coup-liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address I� City M;nt-Qr-_a_ Lot Size/Acreage ;i:4_0 res I Owner's Name ACG Tomato Address Phone 989i Contractor Clark ^I' Address License No. Phone 462-7676 TYPE OF WELL/PUMP. III NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUC IOPR t of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0TH nitoring Well L7 DISTANCE TO NEAREST: SERC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL. 1 r PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F} Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Il: F� Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications I'} Public Cl Other R Delta Depth of Grout Seal Type of Grout I i Irrigation ____�,pprox. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 611 Sealing Material fl: Depth rrr-- Depth" Filler Material & Depth , TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.l {� Installation will serve: Residence Commercial_ Other 1 ` Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. 0 �� Method of Disposal Distance to nearest: Well Foundation Property Line IN LEACHING LINE D N'. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �` J SEEPAGE PITS I I Depth Sire Number a SUMPS GI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ A 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 Sanl'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 su nner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signatu certifies the following: " certify i performance of the work for which this permit is issued, I shall employ persona subject to workman's compensaa- tion laws of C r ' The applic al for II ruire ins tions. Complete drawing on reverse side. Signed X F Title. Date: Sept- 9-0 F DEPARTMENT USE ONLY l Application Accepted by w\ "`� add- •- _"—_ Data re Pit or Grout Inspection by I� Date Final Inspection by Date `/Z �o I Additional Comments: I� i Applicant Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 fk FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY (� DATE p PERM17'NO. k + EH 13-25 tREV.i/n 26 51 I �I��7 lo �--3 EH 14. [,Q l fff l ✓