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APPLICATION FOR PERMIT o �� . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -t ENVIRONMENTAL HEALTH DIVISION .1801 E. HAZELTON AVEzf PRONE (209)488-342 P O BOX 2009, STOCKTON, CA 95201. . . ar PgMIT E LPIRES 1 YEAR FROM DATE ED i;,4 (Complete is Triplicate) Application is hereby made to San Joaquin County for a permitito construct and/or install the,vork herein described. This „compliance with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San application is made in Joaquin County - ., yh I Stocktan Lot Size/Acreage Job Address 6855 W. Eight Mile Road city�� _ Address Phone owner's Name MO 641114 h if #552198 1916)373-111 Contractor Address License No. f Sy.. o -=:=Ph of service well 0 TYPE OF WELL/PUMP: NEW WELL LJ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out Mo itoring Well C3 - -' PUMP INSTALLATION ❑ SYSTEM REPAIR C1OTHER,QC 4'$O Barings DISTANCE TO NEAREST: SEPTIC TANK S€ S WER LINE :'" DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL" OTHER WELL PITS/SUMPS .� INTENDED USE ;--,TYPE OF WELL PROBLEM AREA CON ISTRUCTtON SPECIFICATIONS ; I-) dustrial on Bottom ❑ Manteca Dia64 t Well Excavation Dia. of Well Casing Type of Casing omestic/Private ❑ Gravel Pack ❑ Tracy . o! Grout Seal NIA Type of—. Grout Specifications �}Public F1 Other f-) Delta ` Depth ' I I tftigation I-glApprox. Depth' I 1 Eastern w Surface Seat installed by Repair Work Done O Type of Pump H.P. State Work Dolle S sealing Material& ]Depth 4- t0 full dept Well Destruction ❑ Well Diameteri Depth F'iller,Material,& Depth TYPE OF SEPTIC WORK. NEW INSTALLATION i I REPAIR/ADDITION l I 'DESTRUCTION t I (No septic system permitted if public sewer is available within 206 feet.) . Installation will serve: Residence_ Commercial_ Other ` Number of living units: Number of bedrooms ; Character of soil to a depth of 3 feet: 4 Water table depth` SEPTIC TANK ❑ 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 Cl Distance to nearest: Well 'Foundation Property Line , SEEPAGE PITS 11 - Depth Size Number SUMPS Cl Distance to nearest: Well Foundation - Property Line A. I. DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work willibe 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 workmen's compensation laws of California... Contractors hiring or su contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employp sons suble1,6 workman's ompensa- tion laws of California." *i is 1, all far all required ins coons. Complete drawing on reverse sid The applicant must cpe. p Signed Title: �� Cs.ti✓ Gr .!` te: r , y FOR DE ARTMENT USE ONLY A.�-cw„t-{ Six � - � -►' .�� . � - y,� � -, Application Accepted by Date ��1, ' Area 3W Pit or Grout Inspection by Date lZ -1 '" Final Inspection by Date Additional Comments: 1 Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health,Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, '9 201 FEE AMOUNT DUE AMOUNT REMITTED CKs RECEIVED BY GATE PERMIT'N0. INfO `Y CASH 1.413.2 IREV.119 5) 4 iH:420