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APPLICATION <br /> SAN JOAQUIR COUNTY PUBLIC HEALTH *VICES <br /> ENVIRONMENTAL HEALTH DIVISION `��`��, <br /> IN, PHONE (209)468-3420 <br /> STOCKTON, CA 95219+ <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> ttpplication is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> .roequin County Public Health Services. <br /> Job Address 1721 West Yosemite Avenue C1yManteca , Cot Size/Acreage 2 . 43 acres <br /> Michael Dean c/o 725 N . Main Street , <br /> Owner's Name Central Valle TitleAddress Manteca ,_ CA 95336 p ( 209 ) 995-2I2 <br /> 23762 Foleyy Street , Suite 7 <br /> Contractor Vironex , Inc . Address Hayward , CR 94545 License N0057-70592;hone( 51Q ) 266-0 S 66 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M So i 1 DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR C7 $o r i n g S OTHERS ( 8 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2 1 n C h 5 <br /> n Domestic/Private ❑ Gravel Pack SO i 1 ❑ Tracy Type of Casing Specifications <br /> I"1 Public )(kOther S O r i n g 91 Delta Depth of Grout Seal Type of Grout <br /> 1 I Irrigation 2 0 f b-94 Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. -_ State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION r I REPAIR/ADDITION I I DESTRUCTION 1 I INo septic system permitted if public sewer is <br /> available within 206 feet.) <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Wolf Founaation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L! Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin County <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." <br /> The applicant mu4�s��t call for all required inspections. Complete drawing on reverse side. <br /> Signed X L,, . ,,. Title: Project Manager Date: 5(6-11-f- <br /> .r <br /> FOR DEPARTMENT USE ONLY I <br /> Application Accepted by Date 427- <br /> 4 l n >1: /✓D�U r�G JG' <br /> Area <br /> Pit or Grout Inspection by Date �� Final Inspection by Date <br /> Additional Comments: 11.1 a <br /> Applicant - Re rn 11 copies to: San oaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMIT•rED CASH RECEIVED BY DATE PERMIT'NO. <br /> H 13.241NEv. iMSr Q .� Page ,7 3.4 <br /> 14.26 <br /> 17—Z—�1 yr-E,y 3 <br />