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APPLICATION ,SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Services. Job Address 150 N. SinClail- AveCity Lot Size/Acreage nue Stocktoll- 30 + Acres ' - -- Owner's Name Marley COOIJM Tour CC)Address 5800 Foxridge Dr_ ,Miss' n' KS: Pham 913) 362-1818 bbZUZ Contract Layne 1ivirCrmttenta]_ Address' O1 Val-1 License No600469 Phone(714)355-335 TYPE OF WELL/PUMP: : NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER-V Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE (See a 195111NDATiON AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (See AttaChed Dratair1qS) 1=1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C-1 Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing Specifications ('I Public f:1 Other n Delta Depth of Grout Seal Type of Grout I 1 ifrigation _Approx. Depth l I Eastern Surface Seal installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material &'Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No Septic system permitted if public sewer is V available within 200 feet.i Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character.of soil to a depth of 3 feet: ___ ____ - __- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity NO. Compartments ggrtments PKG. TREATMENT PLT. ❑ PAX bIsOosaI Distance to nearest: Well Foundation ProRlicaturn 992 LEACHING LINE Ll No. & Length of lines Total lengrhYSA FILTER BED ❑ Distance to-nearest: Well Foundation RthiftCF-QkA N('UJN VY t�UBLIk r t SEEPAGE PITS 11 Depth Size A I SUMPS Ut 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 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." Contractor's hiring or sub-contracting signature certifies the following: '9 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 applican st_call for all }ired inspections. Complete drawing on reverse side. 4 Signed X -�-- � CJ _ Title: Branch Manager Date: V2V92 ? _ QFOR DEPARTMENT USE ONLY lqyy Application Accepted by _, �'-'�"�l Data Area'�� Pe y & cti"teZ Date Pa y p Pit or Grout Inspection b 3 �.a ��inal Inspection b '"�"'"°`G"` Date Additional Comments:. W►- Applicant - Return all copies to: an Joaquin County Public Health Services Environmental Health permit/Services �} 445 N San Joaquin, P 0 Box 2009, Stkn; CA 95201FEE �(t INFO AMOUNT DUE AMOUNT REMITTED CASH i RECEIVED BY DATE PERMIVNO. . EH 13.24IREV.tiK5) of v �f�C.�L 3 EH 14•Ze `'�] f 6 v O v