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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, 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. /M.31 Job Address 30000 rsson Rd. , San Jain River Cluh City Tracy Lot Size/Acreage 75x150 Owner's Name STEVE HOUSE Address # 31 EVER EEN Phone 398 - Contractor GARNER CONST Address 7900 Wren Rd. , Oakdale License No.441868 A B Phone 847-2480 TYPE OF WELL/PUMP: N.A. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing J, fa Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications Il Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well! Diameter Sealing Material i Depth Depth Filler Material& Depth- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION XI DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence X Commercial_ Other Number of living units: 1- Number-of bedrooms 3 Character of soM to a depth of 3 foetf sandXWater table depth rwj SEPTIC TANK O Typo/Mfg Capacity No. Compartments _ ? PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. A Length of lines / -?40"' Total length/size .1�0 FILTER BED ❑ Distance to nearest: Well P-- Foundation Property Line SEEPAGE PITS IF Depth —/-X— Sire-sLt OG Number_ < SUMPS IX Distance to nearest: ' Well Foundation Property Lino G3 DISPOSAL PONDS O 70' ea 1 I hereby certify that I have prepared this application and that the work will 6e done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Homs 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 shell n 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 applicant st c for at inspections. Complete drawing on reverse side. signedAaTitle: Owner Date: 9-24-92 FO DEPARTMENT USE ONLY (� c Application Accepted by —Lc M • . _&,*c'nr`Mr Date Z, Area 0 Z\ Pit or Grout Inspection by Date Final Inspection by Z- Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE H 14-26 INFO AMOUNT DUE AMOUNTAEMITTED CK CASH RECEIVED BY D TE PERMIT'N0. . EH 12.2E(REV.I/n 0)C(L 1