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F Y APPLICATION FOR PERMIT,'" x SANFJOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E.OHBOA 2009AVSTOCgTONE CA095201-5420 R P AP EXPIRES 1 YEAR ROM DAT IUB/C K (Complete in Triplicate) RpM Hr�� TnrxR Application is hereby made.to San Joaquin County for a permit to construct and/or install the work Sr ti.describe'd. This 1 application is made in compliance with San Joaquin co> Or inn ce No. 54 and 1862 and the Rules and Ilei gtiorftt'�of San Joaquin County Public Health Services b 0-42 acce I Job Address State HwyRoute 4 and Escalon- ellota Road qty Farmington Lot Size/Acreage Owner's Name Farmington-Fire Protection DistrgiNAessState Hw Ro to 4 E - (2a4-AH---5391 - 1830 Vernon Street, STE. 7 - 1 Contractor Earthtec, LTD. + Address Roseville CA 95678 License No.L- Phone U16) afi2-'L252L of Service Well LI TYPE OF WELLIPUMP: v NEW WELL ❑ Y WELL REPLACEMENT 1-1DESTRUCTION ❑ Out EK Monitoring Well PUMP INSTALLATION C3SYSTEM REPAIR ❑ OTHERGeotechnical soil DISTANCE TO NEAREST: SEPTIC TANK- None __ _ SEWER LINES Nonce DISPOSAL FLD. None _ PROP. LINE In'r orzng 1 FOUNDATION 1St AGRICULTURE WELL ane-_ OTHER WELL Nano PITS/SUMPS ,lane INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f} Industrial ❑ Open Bottom ❑ Manteca Dia. of WtieH Excavation 811 Dia. of Well Casing f Cl Domestic(Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications I'1 Public 1-1 Other n Delta Depth of Grout Seal 40' Type of Grout 11 Irrigation _.Approx. Depth I I Eastern- Surface Seal Installed by Repair-Work Done 0 Type of Pump H,P. State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth Portland cement grout-- t9tal depth Depth I Filler Material & Depth TYPE OF SEPTIC WORK: ,NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i iNailableo septtic withM emitted if public sewer is eet.I Installation will serve: Residence_.:._ Cor=eriCtal Number of living units: I Number of farT—ANP IRED Character of soil to a depth of 3 feet: � .-- Water table depth t SEPTIC TANK, ❑ Type/Mfg peffflit may No. Compartments PKG. TREATMENT PLT. 0 ��h pp nnlet d.ar 111spected Method of Disposal Distance to nearesWOrr� Ping ComtFoun atlon Property Lina �. ,. Balt MOO by LEACHING LINE C1 No. & Length of lines Total length/size y FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth I Size Number 1 SUMPS 0 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, 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." 4 The applicant must call f r all required inspections. Complete drawing on reverse side. +{t Signed X Title: 1k/Na/�'�L d4hSU .0 _ Date: _ � /7�4'/ F R PARTfMENT USE ONLY Application Accepted by Date Area + Pit or Grout Inspection by _ Date Final Inspection by Date E Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health-Fermi t/Servicee 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 i F FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT N0. INFO +f SHf3-241REV.r/951 J8 ~� 1 �I-09 1 E H 14 2a