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1 APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 1 � P O BOX 2009, STOCKTON, CA 95201 a { PERMIT EXPIRES I YE AH FROM DATE ISSUED _ 1 (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This applicstian is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.' ILot Size/Acreage 1 acre Job Address3732 Enr-miul4t-on Rd I a", City S I.k P, Owner's Name Bert°-Forsch 1 e r Address2 216 T h d n _ Phone 669- Contractor C l a r k Well Address 2094 F . Ch License No-33-1-5-6-0—Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17.1 DESTRUCTIOIvkkl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER Q Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS :t-- INTENDED "INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r, 17:1 Domestic/Pflvata ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications Il Public, 1-1 Other f-f Delta Depth of Grout Seal Type of Grout a I I Irrigation —Approx. Depth t 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Deitlon Wall Diameter .611 Sealing Material A Depth T; I i 1;�_�} � t 9 + ^- { s a c k -b o t ^ c. �"r Depth t t 1.(4 Filler Material i Depth i / TYPE OF 5EPTIC ORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system pe(mitted it public sewer 1s available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soG to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity._ No. Compartments PKG. TREATMENT PLT.❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. 6 Length of linea. Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Lina e SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that l 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 the work for which this permit is issued, I shall not I pensation laws of California." Contractor's hiring or sub contracting signature employ any person in such manner as to become subject to workman's com eertifies the fatbwirsq: "I rti that in the parlor nca of the work far which this permit is issued, I shall employ persons subject to workman's compensa- lion laws of C ifornla.' The applica I alt r fired do a. C "plate drawing on reverse side. SignedX Title: Date: 11 Marr-b 91 R DEPARTMENT USE ONLY c L ` Application Accepted byADate { rea Z .� Pit or Grout Inspection by Date I Final Inspection by C/ pate y. Additional Comments: ` GI- t J1I Applicant - Return all copies to: San Joaquin County Public Health Services �� }''� �Tr/G -p�A �rEnv 445iN SannJoaquin, P Permit/Services Bax2009Stkn, CA 95201 4 A-54'Ydl� ��Npi�';A� FEE AMOUNT DUE I AMOUNT REMITTED CK ��` RECEIVED BY D TE PERMIT'NO. INFO n w r EH 1340 IRev.1/w 61 T //�6'J 0/w MWIE��EH 142a i