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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION p� 1601 E. HAZELTON AVE. , PHONE (209)468-3420 A �•rr/ A. P O BOX 2009, STOCKTON, CA 95201 APP�`��"V ' R JT EXPIREgi I YEAR EROM DATE ISSU�NJp (Complete in Triplicate) /R H��i¢�r �`i Application is hereby made,to San Joaquin County for a.permit to construct and/or iaetall the vork d, scribled. This application is made in compliance with San Joaquin County Or ins ce No. 54 and 1862 and the Rules and et;ori of Ban Joaquin County Public Health Services 7 y 4`'+r,, g. Job Address State HwyRoute 4 and Esealon- ellota Road ,ty Fartiington Lot Size/Acreage -0_42 acre__ - i Owner's Name Farmin ton Fire Protection DistojRkessState Hwy Route - Phone{ - 1830 Vernon Street, STE. 7 Contractor Earthtec,-LTD. Address Roseville, CA 95678 License No. C-57J059Phone - ,S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER EX Monitoring Well CJ Geotechnicaloil DISTANCE TO NEAREST: SEPTIC TANK None SEWER LINES HenP DISPOSAL FLD. Nene PROP. LINE 1�Doring ,FOUNDATION 15T_ _ AGRICULTURE WELL Nnne OTHER WELL W P - _ PITS/SUMPS -lue INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I=l Industrial ❑ Open Bottom ❑ Manteca Dia. of Weft-Excavation 8" ___ Dia. of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'i Public 1-1 Other l 1 Delta Depth of Grout Seal 401 Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seat Installed by Repair Work pone (3 Type of Pump H.P. State Work Done _ Well,Destruction O Well Diameter Sealing Material & Depth Portland cement grout total depth -, rt� Depth Filler Material & Depth v1 TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRJADDIT,ION I I DESTRUCTION I I Wo septic system permitted if public sewer is \11 available within 200 feet.) Installation will serve: Residence_ Co erA&I Number of living units: Number ofMXT L. co' t�(� Character of soil to a depth of 3 feet: RtYl—Water table depth 'lJ SEPTIC TANK. ❑ T ype/MfgF � ifh]J No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I� �p3n comnnletppd or inspected Distance to neartss �rNti IP�_ IFoun7aI Property Line aft i4 iSi — 4 � LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Wel 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 subcontracting 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." The applicant must call f r all required inspections. Complete drawing on reverse side. Signed Title: /NG�� f1 edhsuC.Tr AJC Date: —1147_1R.1 R PARTMENT USE ONLY Application Accepted by F ZData C r`� 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 Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO FEE� AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERMIT'NO. E 14-24(REV.trHsk ShS 4' �� EH H 142E