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APPLICATION SAN .QUIN COUNTY PUBLIC HEALTH IVICES ENVIRONMENTAL HEALTH DIVISIW 445 N SAN JOAQIIIN , PHONE ( 209 ) 468- 3420 CopyP O BOX 2009 , STOCKTON , CA 95201 PERMIT 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 compliance with San Joaquin County Ordinance No . 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services . Job Address 749 E Charter Way City Stockton Lot Size/Acreage 1 / 3 Acre Owner's Name Darpetr0 Address3450 E1 Camino , Ceres , Ca . Phone 537 - 0771 contractor Pierson Drilling Addres6II S . 9th St . . ModestDicense No , 614108 Phone545 - 2838 TYPE OF WELL/ PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 40a DISPOSAL FLO , PROP . LINE 101 FOUNDATION 301 AGRICULTURE WELL OTHER WELL 201 PITS/ SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2 n X: Domestic/ Private M Gravel Pack ❑ Tracy Type of Casing -PUC Sch . 40 Specifications I ' 1 Public f.1 Other n Delta Depth of Grout Seal 10 F t a Type of Grout Cement I I Irrigation — APpiox. Depth I I Eastern Surface Seal Installed by Pierson Drilling Repair Work Done ❑ Type of Pump H . P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material d Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK : NEW INSTALLATION 1 I REPAIR / ADDITION I I DESTRUCTION 111No 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 &oil to s depth of 3 feet: Water table depth L - SEPTIC TANK O Type/ Mfg Capacity. No. Compartments r- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line C� LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ 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 hereby cenify that 1 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: '9 certify that in the performance of the work for which this permit is issued, I shell not employ any person in such manner as to become subject to workmen'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 persona subject to workman's compensa. tion laws of California. " The applicant at call for a q i ad in pections. Complete drawing on reverse side. q �j Signed X M1 Title: Date: 7 6 Paul Pierso FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to : San Joaquin County Public Health Services Environmental J Joaquin , P 0 BoxPermit /Services 9 , 445NSanStkn , CA 95201 INFO FElE AMOU((NT��DUE AMOUNT REMITTED CASH R C CK I NED BY DATE PERMIT' NO. . EX 13 N IRW. 1 YM5i Wrl r 5VV g EN 14-M VVgy , �v a�� a- st s� - � -