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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 HERMIT EXPIRES1 YEAR FROM DATE- ISSPED (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 Public Health Servicers. Job Address 25775 Patter �s Ad. Carl Road City�`�Y Lot Size/Acreage 33 000 ft. Owner's llama PiMCItLts CSN Address P. 0. Box 5811, San Mateo, CA 9G402 Phone(415 571-2469 Contractor WestSx Strati FXP1=dCn Address P• 0. Pox 1664, W. SaCrcTrMtO License No. 552198 Phone 916- 373-1118 TYPE OF WELL/PUMP: lNEW WELL M VapOr- WELL REPLACEMENT 171DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION ❑ eXt aCtian SYSTEM REPAIR ❑ OTHER O Monitoring Well C7 I ' DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES �T,� DISPOSAL FLDgQe PROP. LINE ��/ i, FOUNDATION [I> _ AGRICULTURE WELL N/A_ OTHER WELL PITS/SUMPS IST A INTENDED USE ;r TYPE OF WELL PROBLEM AREA : CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom -© Manteca Dia. of Well Excavation Dia. of Well Casing 4 inch r . Cl Domestic/Private D Gravel Pack Tracy , Type of Casing Sch Z40 PT Specifications i'i Public Cl Other , r Delta r, Depth of Grout Seal Type of Grout 1 I I Irrigation 45-M-Approx. Depth I I Eastern Surface Seat installed by DrLller Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth F Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIRIAODITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feei.l Installation will serve: Residence-1 Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 fset�- Water table depth m SEPTIC TANK. . 0 Type/M101 Capacity No. Compartments PKG, TREATMENT PLT.❑ 'I >. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C'1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number i SUMPS LI Distance',to nearest: Well Foundation Property Line DISPOSAL PONDS 0. I i - x I hereby certify that I have prepared this application and that the work will be done in sccar'dance with San Joaquin county ordinances, state laws, an 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 hiring or sub-contracting signature v, 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 Caltfornls." I The applicant call for I r rr nspections. Complete drawing on reverse side. r r Z Signed X� / + �� Titre: Date: � FOR DEPARTME T USE ONLY n? Application Accepted by '��f Date /a '``� �'� Area Pit or Grout Inspection by 11 f ` Date la ��Final Inspection b Data 117 ` Additional Comments: r ro Applicant - Return all copies to: Ban Joaquin County Public Health Services s Environmental Health Permit/Services 445 H San Joaquin, P d Box 2009, Stkn, CA 95201 F FEECKS INFO AMOUNT DUE I AMOUNT�JREMITTED CASH RECEIVED BY DATE �}P^E�RM1T N-O7. 06 . EM1111tR EV,tin5f 4f EH 14.21