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! ' ^Q APPLICATION FOR PERIL I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447,34_' PERMIT EXPIRES 1 YEAR PROM 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Loi o f /2eco/zd Job Address 9542 N. Aipine Rd City St-kn Lot Size/Acreage f20 ac/zeb owner's Name aO,e Jgote to i & Sonb Address 9189 N. k6htey Phone 931-2740 ContractorC-9a2k VeU, Inc. Address 2024 E. Chaztez Clay License No.3 715 6 0 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTS DESTRUCTIOWOVut of Service Well Cl PUMP INSTALLATION x SYSTEM REPAIR ❑ OTHER O Monitoring Well Cl DISTANCE TO NEAREST: SEPTIC TANK f 125 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial O Open Bottom O Manteca Dia. of Well Excavation 7 4 Dia. of Well Casing 8 5 Z Rv XT-KDomestic/Private -'<0 Gravel Pack ❑ Tracy Type of Casing SteP-Z Specifications 4 9 n y,� M Public I'l Other O Delta Depth of Grout Seal 10 0 Type of Grout 9A CLckv CI Irrigation •_._ Approx. Depth D Eastern Surface Seal Installed by ('1/rnnk Repair Work Done U Type of PumpSu.L H.P. 7 112 State Work Done I n A-1a O1/ Well Destruction O Well Diameter 6P r Sealing Material i Depth oe; 0 0 0. . f„4 Q w i Q--4 A 4 6 back Depth aRR Filler Material i Depth In Lx band X cp nn>t TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Ci DESTRUCTION Cl INo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other 1" Number of living units: Number of bedrooms Character of soh to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity-- No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C) No. b Length of lines _ Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 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 taws of California." The spplicr i s ti s. Complete drawing on reverse side. Signed /�(/ catl or I Title: V% Uaak GleLe, Inc Date: 22 dune 92 ^)FO DEPARTMENT USE ONLY Application Accepted by Date Area Pit orrout napectan by �- Date�— Final Inspection by Date all 6 : f �_ r Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES OlA „�M^4%bt1J46Te4 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 01J to 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13-24(REV.1iO45l . O./ �- lnl0 7 'I Z �i2- - -�1 EH 11.26 � !r - � 3i6