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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 0 BOR 2009, STOCKTON, CA 95201 ZZAMIT EXPIRES 1 YEAR FROM DAT ED (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 i Joaquin County Public Health Services. 1 Job Address City Tracy Lot Size/Acreage --res ar•res Owner's Name Tracy Constructors Address Same Phone ContractorClar Address License No, 71 r,9 one TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTI kb Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0TH Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 70 r FOUNDATION AGRICULTURE WELL OTHER WELLLIl.Q'— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public Cl Other fl Delta Depth of Grout Seal Type of Grout 11 Irrigation — Approx. Depth I i Eastern Surface Sedi installed by Repair Work Done 12 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter h" Sealing Material & Depth _f _��_ �Op 280 ' Depth 2 8 Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.i 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. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS IJ Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 certif in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californi ' The applican s II f r in c' ns. plate drawing on reverse side. Signed X Title: VP Clark Well Date: 12 Sept 90 i FO DEPARTMENT USE ONLY 9 Application Accepted by Date ` Area Pit or Grout inspection by Date Final Inspection by Data Additional Comments: 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 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT'NO. EH -241REV.tiKSi R EH �4-2e