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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMMTAL ,HEALTH DIVISION <br /> 1601 F. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCgTON, CA 95201 <br /> kEMIT E2W1_REd I YEAR FROM <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vont herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Hulce and Regulations of San <br /> Joaquinounower ark Marity Talc lI th 8ervieesna . <br /> Job Address 14900 W Highway 17 City T.r„I; ,pLot Size/Acreage _/Q <br /> /1 `30 t.►/< ,� <br /> Owner's Name Westrec Marinas Address _aamQ ._ Phone — <br /> Control or Address License No. _RR'�itr3} Phone <br /> TYPE OF WELL/PUMP: •�v 1. NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well 0 <br /> ►T - - -PUMP INSTALUTION.Q `SYSTEM REPAIR 0 OTHER W Monitoring Well d <br /> •OISTANCE.TO NEAREST; SEPTIC TANK T 1'SEWER LINES 'v DISPOSAL FLD. tffihnical Invs. <br /> L. FOUNDATION AGRICULTURE:WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0Industrial O Open Bottom 0 Manteca. Dia. of Well Excavation b In• Ilia. of Well Casing <br /> t•, <br /> C.1 Domestic/Private 0 Gravel Pack _, O Tracy 'Type of Casing n/a Specifications <br /> I'1 Public 1'1 Other'% r. "'n Delta jDepi al Grout Seal full depthType of Groul_r_Pment <br /> I I trriga[ion T Approx, Depth IA faslern a Surflica Seal installed by <br /> Repair Work Done 0 Type of Pump w H.P: I± _ State Work Dona_ <br /> Well Destruction Q Well Diameter sealing llateriil & Depth Est. 25 f eet i <br /> Depth Ei'illeY HAterlel A Depth cemerlt, full dapLhj <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.i <br /> Installation will serve: Residence_ Commercial Other d i <br /> Number of living unite: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. © TypelMfg Capacity No. Compartments <br /> t Y <br /> PKG, TREATMENT PLT.Cl � Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total iongth/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Properly Line <br /> SEEPAGE PITS I I Depth Sire 7Vumbar <br /> SUMPS LI Distance to nearest: Well Foundation ` Property Line ; <br /> DISPOSAL PONDS Cl <br /> 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 <br /> rules and regulations of the San Joaquin County <br /> 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 I <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ Persons iubject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. C plete drawing on reverse side. <br /> � �] <br /> Signed 'f Title:_{„tf�L• Date: <br /> FOR P TMiFNT USE ONLY <br /> Application Accepted byDate. P ~�f� Area <br /> Pit G nspeclion bv2' � Date L Final Inspection b Date2 <br /> /J r <br /> Additional Comments: 2 '—aw 0►]QrJ� �f' <br /> Applicant — Return IL11 copies to.' San Joaquin County Public Health 6 `• ,Ir-1 2_G ��� Yd <br /> Servicea, Environmental Health Permit/Serv�icetZ-" <br /> 1601 E. liarelton Ave., P 0 Box 2009. Stockton, CA 95 201 <br /> FEE AMOUNT DUE A UNT gEMITTED CK RECEIVED BY DATE PERMIT•ND. <br /> INFO CASH <br /> . EM 1324{REV.tin61 gqoa 2 .I Toa-85 <br /> EM:!•70 <br />