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• APPLICATIOq_E2R BERNIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , 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 575 Industrial Park Dri Ve City MAnf-pCa Lot Size/Acreage I- 9 arrpc _ Owner's Name DitZ Brothers Address 170 Pioneers Rrl Wa GcnVi 11 Stone 95076 Contractor All Terrain Exp. Address Pleasan±_GroVe,Ca• License No. __A33-8-JE Phoned - 99 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well . 3 DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES 1 n 0 ff _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL12IDft.OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation 1nC eS Dia. of Well Casing 2 XI Domestic/Private D4 Gravel Pack ❑ Tracy Type of Casing_PVC Specifications sched. 40 1'1 Public 1-1 Other fl Delta Depth of Grout Seal 20 feet Type of Grout Neat Cemen I I Irrigation 35 fit.Approx. Depth I I Eastern Surface Seal Installed by Driller Repair Work Done L7 Type of Pump _ H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material i Depth IU /tV TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is l_Al available within 200 feet.l 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 Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line c LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line {�V� SEEPAGE PITS 11 Depth Size — Number r SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 workmen'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 workmafi s compensa- tion laws of California." �. The applic(aJp-,frt,u1st call for all required inspections. Complete drawing on reverse side. �1 Signed tJ. ��1�-`-[.7-!f.�J CVv.� Title: ("o f ILc.QFiL Date: FOR DEPARTMENT USE ONLY Application Accepted by Date If- -,g// Area rnul+3 Pit or Grout Inspection by Date a� Final Inspection byDate, -. Additional Comments: -- Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO INFO �f • EH1 -24 IREV.IIsi �1" Xi .' 9 3 EH IF211