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t APPLICATION SAN JOAQUIN COUNTY ENVIRONMENTAL PHEALTH DIVISION UBLIC TH RV I CES SCANNED 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) .t 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. 549 and 1862 and the Rules and Regulations of San p Joaquin County Public Health Services. { Job Address 2425 N • Alpine R d City's t k n Lot Size/Acreage Owner's Name Ennis RarnOS Address 9 9 R W, Phone i _. r Contractor C 1 a rk We-1 1 _ Address n i. >, License Na. a Phone c 1, r t e F--- - TYPE OF WELL/PUMP. NEW WELD w, WELL REPLACEMENT.171 DESTRUCTION C Out of Service well ❑ PUMP INSTALLATIONN3 X SYSTEM REPAIRL-1OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE +15 t FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 Hit^ Dia. of Well Casing p 'r p X[X Domestic/Private X)�kGravel Pack L1 Tracy Type of Casing— RUC SpecificatiorisCf 96Q F1 Public 1.1 Other C Delta Depth of Grout Seal Type of Grout9 s a e � �} ! r XIXi Irrigation .Approx. Depth l I Eastern Surface Seal Installed by I Repair Work Done 0 Type of Pump _Ig 11 h H.P. 5 - State Work Done ft Q _, , Well Destruction - ❑ Well Diameter, r .Sealing Material 6 Depth Depth Fillei,1Material &'Depth TYPE OF SEPTIC-WORK: NEW INSTALLATION I I REPAIR/ADDITION I I -DESTRUCTION I I (No septic system permitted if public sewer is st I available within 200 feet.) Installation will serve: Residence_` Corhmercial_` Other Number of living units: Number of bedrooms r Character of soil 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 w FoundationProperty Line { LEACHING LINE ❑ No. if Length of lines Tdtai Idngth/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line j I SEEPAGE PITS 11 Depth Size Number t SUMPS Ll Distance to nearest: Well Foundation Property Line { DISPOSAL PONDS ❑ t 1 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 i 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 1 employ any person in such manner as to become subject to workmen's compensation taws of California." Contractor's hiring or sub-contracting signature certifies the following; "I certify that in the perlorman a of the work for which this permit is issued, I shall employ persons subject to workman's compensa• P tion laws of Cali rnia." The spptican t all f r i io omplete drawing on reverse side. i _ .. j Signed Title: VP Clark W Date: 91 J111je FOR DEPARTMENT USE ONLY Application Accepted by Date �` Area ��1 y _ Pit Grou spection by Date r Final Inspection by Date Additional Comments: ' Applicant - Return all copies t San Joaquin County Public Health Servic j Environmental Health Permit/Services + 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 of INFO AMOUNT DUE AMOUNT REMITTED CABH RECEIVED BY DATE PERMIT'NO. 1 z i ' a EM 1344 IAEY.t/h sl EH 14-Ie D r t7'Q 1��( V �� .J 73