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a _i13 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t"ZENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 96201 <br /> j (209) 468-344717 <br /> s <br /> ¢ EMIT EXPIRES I YEAR ?9QM.PATE_19SUI <br /> Complete in Triplicate) ± <br /> I,Y;rlication is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> mailion is made in comt liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San + <br /> Ztt,tsquin County Kbllc Health Services. <br /> 'Job Address r► city LAthro Lot Size/Acreage ±600 <br /> Owner's Name , Crn%eroadS Assaciates Address 1731 Techno3 ogy_Drive, Suite 3gane 408-453-3750 <br /> 4- <br /> San Jose <br /> Contractor Fxoloration Address 2825 E. Myrtle St, -StoekLtgAse No.1q12268 Phot)909-465-8712 <br /> x TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION Out of Service well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER ❑ Monitoring Well L7 <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK40'(C1 OSrr�1 FWER LINES .>100' DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 30_ AGRICULTURE WELL>_129!_ OTHER WELL PITS/SUMPS , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0omesticlPrivate ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> .J Public f-1 Other ❑ Delta Depth of Grout Seal Type of Grout I <br /> M briustion Approx. Depth ❑ Eastern Surface Seal Installed by I, <br /> Repair Work Done U Type of Pump H.P. �,S i to Work Dona <br /> Will Destruction Well Diamet Sealing Material E Depth UnnOWn <br /> Depth unknown_ a Filler Material i Depth unknown <br /> l' TYPE OF SEPTIC WORK: NEW INSTALLATION fl REPAIR/ADDITION M DESTRUCTION G (No septic system permilted if public sewer is �} <br /> available within 200 feet.) . <br /> Installation will serve: Residence Commercial___ Other <br /> Number el-f living units: Number of bedrooms <br /> °"`� Cht• .;cei':�s1 soil to a depth of 3 feet. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> t PKG. TREATMENT PLT.Cl Method of Disposal <br /> is Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br />(. SEEPAGE PITS 11 Depth Sire Number <br /> r f ;=r;PS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin County <br /> t� <br /> Home owner or licensed agent's signature certifies the followrng: "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 subtect to workman's compensation laws of CaNtornia." Contractor's hiring or subcontracting signature <br /> eenifies th lowing., "I cenrf that in the performance of the work for which this permit is issued, t shall employ parsons subject to workman's compensa- <br /> tlon lawn o stlfar I" 1 <br /> The ippfican must c for Il r !red inspections. Complete drawing on reverse side. <br /> F <br /> $igned Title: Date: <br /> s <br /> n.DIPVATMENT USE ONLY <br /> qr�ApOli on Accepted byDate t X LV Area <br />` pit or Grout Inspection b Date Final Inspection by Data /a <br /> Additlonal Comments: It <br /> k- I:pplicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> A 445 if SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEEf <br /> INFO AMOUNT DUE AMOUNT REMITTED CKSH R CEIVEO 9Y DATE PERMIT N0. <br /> EH 13.2-A tFIEV.1/0151 <br /> EM',1-211 <br /> F <br />