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APPLICATION FOR PERMIT I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 ` PTRI[IT EXPIRES 1 YEAR ORQX DATE lag= (Complete in Triplicate) Application is hereby made to Sa.n Joaquin County for a permit to construct and/or install the work herein described. This i application is made in ccmWli&nce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 29879 S. CHRI SMAN RD. City TRACY— Lot Size/Acreage 1 I ��HARD T. MAYERS 2 9 5 7 3 S Phone 0 Owner's Address � I Contractor SAME Address AMP License No. Phone TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well �! PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLO. PROP. LINE _2.0 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing " Domestic/Private M Gravel Pack X Tracy .Type of Casing PLASTIC Specifications M Public (I Other ❑ Delta Depth of Grout Seal 10 0 r Type of Grout CJ Irrigation 1-UApprox. Depth ❑ Eastern Surfaee Saul Installed by nWNFR Repair Work Done U Type of Pump Sub H.P. State Work Done__T,NSTAI,I D Well Destruction 0 Well Diameter 6" Sealing Material L Depth Depth 1 7 0 r Filler Material & Depth TYPE OF SEPTIC WORK: NEW"INSTALLATION D REPAIRIADDITION lrf DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet-1 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, C] Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property line SEEPAGE PITS 11 Depth Size Number SUMPS ll 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*sjgnatu re 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 subiict 1n 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 iiisued,'l shall employ persons subject to workman's compensa• tion lours of California." The applicant must call for It requir. inspections. Complete drawing on reverse side. I Signed Title: OWNER Date: 1 f 77 f 91 FOR DEPARTMENT USE ONLY- r Application Accepted by /16Date Area Pit or Grout Inspection t Date, '+ Fini6lnspection by r Date+ �� Additional Comments. Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES ■ 445 N SAh.-JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 e 'y INFO EEE AMOUNT D,.UEE� AMOUNT REMITTED CK RECEIVED BY y DATE 9 9PERMIT'NO. • EH 13.24 IREV,I/A5) S. vV � Off?3 r7 G L/ GIS 6�p4� EH 1,,4,26