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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 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 conatruct and/or install the vork 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 Drive - City Manteca Lot Size/Acreage 3 . 9 acres Owner's Name DJ tZ BrOthtzrS Address170 Pi nnaorc RA WAt-cnnvi l IQ Phone 95076 Contractor AddressPleas ant Grove . CA. license No.._ 437836 Phone —7 199 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well EX DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES 100 ft. DISPOSAL FLD. POOP. LINE _ FOUNDATION AGRICULTURE WELL:L_20 OTHER WELL PIT5/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing a Domestic/Private $l Gravel Pack ❑ Tracy Type of Casing PVC Specifications crhaA —40 I'I Public 171 Other n Delta Depth of Grout Seal 20 feet Type of Grqut CeRfP I I Irrivatlon 35 f.tAPprox. Depth I I Eastern Surface Seal Installed by Driller Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material 6 Depth y' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is C available within 200 feet.) Installation will serve: Residence_ Commercial_ Other V Number of living units: _ Number of bedrooms L' Character of soil to a depth of 3 feet: Water table depth Z, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments C PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. 8 Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS It 0 t4- Size Number SUMPS LI Distill to nearest: Well Foundation Properly Line t` DISPOSAL PONDS ❑ 1 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 laws of California." The applican st call for all re wired inspections. Complete drawing on reverse side. Signed X �-^-�v �' \ W"r Title: �tiV I I 6! —'�'`-F"�l Date: ��1/"/4� OGADtn/Eil JV-,l&60 FOR DEPARTMENT USE ONLY llgl Application Accepted by f!`/�".'i`r�._u"' Oate F/ / Area /y Pit or Grout Inspection by Date Final Inspection b Dated Z4 Additional Comments: Applicant - Return all copies to: Sm Joaquin County Public Health Services, Fbviroamental Health Permit/Services C� G 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT OUE AMOUNT REV ITTEDCK a RECEIVED By DATE PERMIT NO. INFO �jy/ CAS/N^ Q C� . EH 13-24IREV.11-51 �m S-/ lIC5 Q - 3'71 EH 14-10