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APPLICATION _ f4 r JOAQOIN COUNTY PUBLIC HEA4 SERVICES ENVIRONMENTAL HEALTH DIVISION " 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 > PERMIT_EXPIRES> 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made to Sea Joaquin County for a per-nit to construct and/or instal the work herein described: This' syplication is made in compliance' with San Joaquin County Ordinance, No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Ser Ices. Job Address 30-4-9--W . H i g j]W a y 12 City L o d i t.ot size/Acreage Owner's Name Surendra F . 'Patel Address 607 So . Cherokee Phone209-368-1152 P . O . . Box 950 209- '� ContractorO i t Equipment S e r v .Address S a n Af1ldreas i.icense No. 323417 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERXX soil ftot}it1�Drr x ittg Well ❑ nC� DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS C1 tndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing II n Domestic/Private ❑ Gravel OaW ❑ Tracy Type of Casing Specifications ` 11 Public n Other Fl Delta Depth of Grout Seal Type of Grout I I trriomion _Approx. Depth I I Eastern Surface Saul installed by Repair Work Done L3 Type of Pump H,P. State Work Done Well Destruction ❑ Well Diarnetw Sealing Material 11 Depth cemerit/bQnh-)nice 20 - Depth the Filler Materiel 1. Depth x TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I 1 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 C1 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance ib nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total langth/size . FILTER BED Cl Distance to nearest: Wall Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance io nearsu. Well Foundation Property Line DISPOSAL PONDS ❑ _4j 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, .ani rules and regufahons of the San Joaquin ii County Home owner or licensed agent's signature cartifies the following: "1 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'6ecorne subject to workman's compensation laws of California.- Contractors hiring or sub-contracting signature certifies the following: "I certify that in the psrfoimanca of the work for which this permit is issued. I shall employ persona subject to workman's compenu. tion lawn of am The apps' Rt cal .for ei tiolls. Complete drawing on reverse side. Signed II Title: _ Pre-z . .-Oilr E q b i_p m e n t Date: 11/ 2193 ith A . a Iia FOR DEPARTMENT USE ONLY eTV1Ce Application Accepted by Oate ✓ ✓' ` -1 At" Pit or Grout Inspection by Date Final tnsoection by IWAt Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Sovironmental Health Permit/Services 445 N San Joaquin, P O Box 2009,: Stkn, CA 95201. :FEENFO AMOUNT OUIE AMOUNT REMITTED CK 11 CASH RECEIVED 9Y DATE PERMIT'NO. EH 111.IIIEy.%rRel 7P505 5� yIN 0029 EH t42a i1;.j