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. APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIMTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468--3447 2X"TT EX Y R (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 1s trade in C0114illance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 150 N. Sinclair Avenue City_.StOa:LQn— Lot Size/Acreage 3(}+ ACrt-, 66202 — Owners NameMarle C001i'na Tower CO.I Address 5800 FOXrid a Dr Phone( - 85284 x Contractor D_ a ___ Environmental Address.002 S. Hard Te e AZ License No.600469 Phone 496-fiq00 TYPE OF WE , • NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER 7 'Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE See PEg.G- GfONDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (See Section 2A 'and DwgS) n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private C) Gravel Pack ❑ Tracy Type of Casing Specifications - M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout CJ Irrigation Approx, Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material 4 Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION Cl DESTRUCTION GI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_,", Other Number of living unite: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity-„__ No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 ) Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 signaiurs 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." Contractor's hiring or sub-contracting signature I certifies the following: "I certify that in the performance of The work for which thispermit is issue . shall sin to p y persons subject to workman's compensa- tion laws of California." dI The applicant must call for all required t • Complete drawing on reverse side. Signed �--� Tide: Date: —:=tI aRA i l DEPART ENT USE ONLY / Application Accepted by G Date s � / Pit or Grout Inspection by Date % Final In:paction by j Date Additional Comments: Applicant - Return all Copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P"0 BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK � INFO CA RECEIVED BY DATE PERMIT'NO. • EH 13-24 IREV. f . ainS� ag 6-5 yds/�i y�_orzr