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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT MIRES 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. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 9251 Wolfe Road_ City F'rR;a 14('a Ufft Size/Acreage s----- __ Owner's Name Ray Muller Address same Phone} - Contractor Clark Well , Inc . Address 2024 R (;,.11a.Ltpr Wn3; License iVo.�77 S�jQ Phone TYPE OF WELL/PUMP: NEW WELL iOX WELL REPLACEMENT n DESTRUCTION ❑ Out of service Well Cl PUMP INSTALLATION I�X SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 4=1 QQ I-_ SEWER LINES DISPOSAL FLD. PROP. LINE fig+ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1-:2 11 Dia. of Well Casing r,t+ f.*ijomestic/Private X[236ravel Pack C] Tracy Type of Casing-PVC Specifications-6 �r—T-o^rs• V1 Public 1-1 Other n Delta Depth of Grout Seal i n nr Type of Grout. I I lrrigation — Approx. Depth I 1 Eastern Surface Soul Installed by , Repair Work Done 0 Type of Pump Sill) H,P. � State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted it public sewer is available within 200 feet.) installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms `Character of soil to a depth of 3 feet: Water table depth O SEPTIC TANK CIType/Mfg_L '- - Capacity No. Compartments PKG. TREATMENT PLT. 0 - Method of— Disposal-Distance to nearest: Well Foundation Property Line y LEACHING LINE ❑ No. & Length of fines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS L) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 4 f 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 paiformance 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 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 applican s call r r it n ction Co tele drawing on reverse side. Signed Title: Date: 2_5_ Ma 3x 9 FOR DEPARTMENT USE ONLY s Application Accepted by Date �25� 3 Area Pit orGrou Inspection by Date T Final ins I ' Inspection b Y_ rf. /�B..i�.2 cv) Date Additional Comments: C D-- "& Applicant - 'Return all copies to; San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, ox 2009, Stkn, CA 95201 IMFO AMOUNT DUE AMOUNT. CK CEIVED BY E PERMIT'NO. N EH 13-24 IREV.i/as)U) (AYZA I- I EH 1426 I `L v