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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONISENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROId D TE ISSUED (Complete in Triplicate) Application is hereby made to Ban 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 419 Mt. Diablo East side of buildir City Tracy Lot Size/Acreage 4 Ac owner's Name Bill Assad Address 1930 Tracy Blvd. Phone 835-4444 Contrattor Quality Control Isms. Address 1295 N. Emerald Modesto License No. NIA Phone 527-4940 TYPE Of WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER (R (2 fo6at)VCill. n Wel DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE e_ T1 s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS --to 5 ft INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing CT Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public [1 Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done -0•_ Type of Pump H.P. State Work Done- Weil Destruction ❑ Well Diameter Sealing Material i Depth Dep h tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIAIADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 fest.l Installation will serve: Residence_ Commercial Other ;r 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 Distance to nearest: Well Foundation Property Line CY LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS t 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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, 1 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 Eaves of Calif la." The applicant ympt call for all inspections. Complete drawing on r erre side. Signed Title: _ _ x „_.� - Date: FOR DEPARTMENT USE ONLY � p Application Accepted by Date .k,2=JV9ff2> _ Area ,lam l Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. / . EH 1241t1EV.iiN6t G C� q3 EN 14.�•2e 1