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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL ,HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOR 2009, STOCKTON, CA 95201 REMIX 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. 5h9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Tower Park Marina Job Address 14900 W. Highway .12 City T.r,.1; hot Size/Acreage 14/a //S:3o Owner's Name WPRYrPC- Mari nq S __ Address same Phone — Ii 3`_Q/F' S's�m Contractor address _- ,......_._.._,.,&bk License No. ��Phone 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ rvt L. Monitoring Well rr ii -PUMP INSTAL;LATION.0 :SYSTEM REPAIR 0 OTHER M ❑ 1 -DISTANCE.TO NEAREST: SEPTIC TANK SEWER—LINES _ DISPOSAL FLD, pohnical Invs. ? ;yc FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation 8 xn• Dia. of Well Casing C.1 Domestic/Private ❑ Gravel Pack +rye ❑ Tracy :TypeofCasing n/a Specifications F1 Public 1:1 Other"' r `n Delta b � � Depth of Grout Seal u eft Type of Grout !'Pm Pnt I I tfrigation —Approx. Depth 1�'I Eastern + Surface Seal Installed by Repair Work Done U Type of Pump H.P. ) State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Est. 25 feet Depth Filler Material & Depth cement TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I ! DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms C Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ TypelMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 1 Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE 11 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _fiumber SUMPS Ll Distance to nearest: Well Foundation 4 Property Line DISPOSAL PONDS C1 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 persons subject to workman's compensa- tion lows of California." _ 1 b The applicant must call for all required inspections. C plate drawing on reverse side. r t SignedTitle: t bate: Ste-Vf— ZFORIP TMENT USE ONLY _ Application Accepted by Date 9/ tl Area a/ Pit Gro napection by Date 2 Gi Final Inspection b_ � C�� Data r Additional Comments: ' Applicant — Return all copies to: San Joaquin County Public Health 6,-7'^(: 1��,��++ �D�1' ? , c1d Services, Environmental Health Permit/Sercesa 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEINFO AMOUNT DUE A OUNT REMITTED CASH RECEIVED BY DATE KV PERMIT NO. j EH 14 24 IREV.t i n SI gq _ 00 Q •i„ ct,