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APPLICATION FOR PRUIT i SANAQUIN COUNTY PUBLIC HEALTHVICES ENVIRONMENTAL HEALTH DIVISI 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOC%TON, CA 95201 ' E%P RES J YEAR FROM DATE ISSUM (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 corapliarace with San Joaquin County Ordinance No. 549 and 1862' and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 11409 Rosernar;e- Lane City Stockton Lot Size/Acreage Eugene and 5575 N. Homan Road Owner's Name Lydia Tobias Address Phone I � 47 Louise Street �J 987 Contractor Precision SafnAilng __Address License No. fi3�+-�R7 - Phone - TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER G Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK NIA SEWER LINES 40 ft. _ DISPOSAL FLO._ N/A_ PROP. LINE -ID—ft. FOUNDATION _LO ft. AGRICULTURE WELL -KJ-A- OTHER WELL 1 na ft_ PITS/SUMPS IIA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ci Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing N A Specifications 11 Public K Other fl Delta Depth of Grout Sea, 26 ft• Type of Grout CPMPnt I I Irrigation -2h Approx. Depth I I Eastern Surface Sedl Installed by_ -N 16 Repair Work Done ❑ Type of Pump N.P. State Work Done Well Destruction IS Well Diameter -inch Seng Material & Depth neat cement 26 ft_ rql v Depth . 26 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 y available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soli to a depth of 3 feet: 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 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well 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 peroon 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 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 aa licant must c 11 for all required inspections. Complete drawing on reverse side. . f Signed Title: Dal 7 FOR DEPARTMENT UVLY Application Accepted by Date �` Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: er-, j I Applicant - Return all c pies to: San Jo4quin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED (CASH �1RECEIVED BY �7 DATE PERMIT*JNO, • EH 17.24 YtEv.l M 51 EH 11.25 (f r