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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY.PUBLIC HEALTH SERVICES ENVIRONMENTAL"IiEALTH DIVISION 1601 E. HAZELTON AVE., PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PEUIT 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. a Job Address 8495 Stephens Rd, City Stockton Got size/Acreage � �r Owner's Name Michael & 'Brenda iia address 8495 Ste_ h-en.s Ed,Stockton Phone 931-316-1 Contractor Richard Emery Con addlress 26-55 E„ Miner' rt License No. 447409 Pltone 46-4-1441 TYPE OF WELL — NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out.of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 11 .' OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private CXGravel Pack 0 Tracy Type of CasingS' PVC Specifications r I') Public i-1 Other n Delta Depth of Grout Seal l 0 0 Type of Grout I I l(rigation —Approx. Depth l I Eastern Surface Seal Installed by Mnrmnn Pilg;p Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Materiel & Depth Depth T ` Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION IX REPAIR/ADDITION { I DESTRUCTION I 1 iNo septic system permitted if public sewer is available within 200 feet.) x Installation will serve: Residence X - Commercial Other Number of living'uniti: ` Number of bedrooms 3 r Character of soil to a depth of 3 feet: Water table depth 9 6 SEPTIC TANK. ❑ Type/Mfg P &_'L;' Concrete Capacity 1200 GFII.No. Compartments 2 PKG. TREATMENT PLT. ❑ , Method of Disposal Distance to nearest: Weil Foundation 'Z c7 Property Line `fib LEACHING LINE 0 No. & Length of lines._3) 10 0 'K toric Total length/size FILTER BED D Distance to nearest: Well 140 a Foundation 20 Property Line 80 t� SEEPAGE PITS I I Depth 25 �` Size 26 _' Nymber 3 SUMPS LI Distance to nearest: Well :?=q10 Foundation—/ rt/ 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: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- tion laws of California." The appli usl call for all required inspections. Complete drawing on reverse side. 7 Signed "J Title Date: ! FO DEPARTMENT USE ONLY t Application Accepted by � Date Area C� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services ` 1601 E. Hazelton Ave., P 2009, Stockton, CA 95201 ` FEE AMOUNT DUEA OUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO / +yt CASH « EH r3-241REV.i/n5) 1 �{ EH 14.26 !! I