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APPLICATION FOR PERMIT � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL ,HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PER-MIT 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Tower Park Marina Job Address J 4900 id Ili 2hway 12 City i C)di Lot Size/Acreage —n/., Owner's Name WPStrPr Mari nam __ Address Same Phone - r Contractor t A %ddress ,— ilp f License No. Rft7� _Phone 4 TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT C DESTRUCTION ❑ Out of Service Well r\. w LMonitoring Well ►7 -r"" -^- PUMP INSTALLATION.E3 1 SYSTEM REPAIR ❑ OTHER X U 4 , hnical Invs. •DISTANCE,TO NEAREST: SEPTIC TANK SEWER_LINES�_ DISPOSAL FLO P 4pot CI E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial O Open Bottom L) Manteca ` Dia. of Well ExcavationIi Dia. of Well Casing [I Domestic/Private C1 Gravel Pack ' C Tracy ! Type Casing n,/a Specifications _ —_� U l C ePt I'1 Public I 1 Other r `1l Delta IDeptti of Grout Seal Type of Grouter mr nt Y I I Irrigation —Approx. Depth I I Eastern + Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. I ' State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Fst. 25 feet Depth Filler Material b Depth cement full depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl 11 i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size < C FILTER BED C) Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ ,Number SUMPS LI Distance to nearest: Well Foundation Property Line C DISPOSAL PONDS ❑ I 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 t 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, 1 shall employ persons subject to workman's compensa- tion laws of California." _ The applicant must call for all required inspections. C plate drawing on reverse side. ` 1 t /q Signed / Title: Lr C / � r t Date: 54,e FOR D P TMENT USE ONLY 3� 99 Application Accepted by Date �—( / Area /3 Pit r Gro inspection by�w�� Date /"� � Final Inspection bey �� tom----�/ Date 2� / Additions) Comments: `g� CGU w'd4 �1� /;�'I Applicant - Return all copies to: San Joaquin County Public Health ��, VJDn Services, Environmental Health Permit/Serv4clr 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE A OUNT REMITTED CASH. RECEIVED BY n DATE PERMIT NO. EH 13.24 IREV.I/n 51 q Q t� /}( .�^V L 1</ ;,( (n.q I Q -n