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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 O 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. Job Address 510 North Main Street City Manteca Lot Size/Acreage Owner's Name Royal Oak Savings Address 358 North Main Street Phone 239-1155 Contractor WHF Environmental Address 4843 McHenry Avenue License No. NSA Phone 579-8138 TYPE OF WELLIPUMP: NEW WELL C] WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ Sod PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER aonitori Well C7 n 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 C7 Industrial ❑ Open Bottom N Manteca Dia. of Well Excavation Dia. of Well Casing [ _ El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Vi i'1 Public is Other I1 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seai Installed by Repair Work Done L3 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I i DESTRUCTION I i INo 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal L Distance to nearest: Welt Foundation Property Line G� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I ) Depth Size Number SUMPS 0 Distance to nearest: Well Foundation_ _ Property Line 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applica must call for all equira 'nZllm . Complete drawing on reverse side, p Signed X.d-,/ Title: President Date.- FOR ate:FOR DEPARTMENT USE ONLY Application Accepted by Date 3'z 8 90 Area Pit orGrout spection by Date y !82 Final Inspection by!� .T%. — Date y �U Additional Comments: - — Applicant - Return &11 copies to: San Joaquin County Public- th Services, Environmental Health ermit/Services 1601 E. Hazelton Ave., P 0 Box 009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO r EH 13-24IREV.1/H51 EH 14.21 �(