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Am 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 E_RLtIT 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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. X Job Address 31130 S. Corral Hollow Road Cit Tracy Lot Size/Acreage 45 San ..Joaquin County J. H0LL4 � 1. r° Owner's Name Public Works Department Address 1810 E. Hazelton Avenue Phone (209) 468-3066 Contractor s Address J 5' A& License No. �o�f .� Phone 721 TYPE OF WELL/PUMP: NEW WELL 4B WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 501 FOUNDATION AGRICULTURE WELL OTHER WELL1000 ° PITS/SUMPS ., INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing 811 IX Domestic/ Private ® Gravel Pack ❑ Tracy Type of Casing_ Steel Specifications Attached r I1 Public (-1 Other f -I Delta Depth of Grout Seal 200 Type of Grout Cement I I Irrigation 6011L. Approx. Depth I I Eastern Surface Seal Installed by $ Repair Work Done ❑ 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 I I REPAIR/ADDITION I I DESTRUCTION I I (No 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. D Method of Disposal Distance to nearest: Well Foundation _ Property Line LEACHING LINE Q No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i f4 I 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, 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, I shall employ persons subject to workman's compensa- tion laws of California." t The applicant I for oil to re insPections. Complete drawing on r9grrse�sidde, p► ! Signed X Title: / w.^ Date: FOR DEPARTMENT USE ONLY jam, Application Accepted by ` Date Area 1 ^" Pit or Grout Inspection by Additional Comments: Date Final Inspection by c i Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 EH 13-241REV. ries EH 14.26 Date FEE INFO AMOUNT DUE ED AMOUNT REMIT -TED 11 CK CASH RECEIVED BY DATE PERMIT' NO. P9.2i2 01