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e APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERV C S., ., ENVIRONMENTAL HEALTH DIVISION �`� � � i�I�/�� P O BOX 2009, STOCKTON, CA 95201 (209) 468--3447 = Q Ogg YEAR FROM DAIE ISSUIM ENVIRONMENrA (Complete in Triplicate) AFRMl7 EALIR Application is hereby made,to San Joaquin Count for ,""'CE PP Y q y permit to construct and/or install the work herein described. his 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. Job Address 1012 W. Yosemite City Manteca Lot Site/Acreage .36 Acres Owner's Name Kenneth Hafer Address 232 N. Lincoln Manteca CA Phone 823-3448 Contractor Consolidated Testing Address 1055 W. Morton Ste. C License No.C57 544541 phone (209) 781-0 71 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L!lx DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom 13 Manteca Dia. of Well Excavation Tr- Dia. of Well Casing 411 U Domestic/Private O Gravel Pack C3 Tracy Type of Casing Sch. 40 PVC Specifications Flush Thread d M Public Cl Other ❑ Delta Depth of Grout Seal 24.5' Type of Grout Neat Cement tr Irrigation Approx. Depth I:1 Eastern Surface Seal Installed by Chem-grout e_Uipe ant Hite Repair Work Done U Type of Pump H,P. State Work Done Wall Destruction O Well Diameter 411 Sealing Material i Depth Bentonite hoTe__Tu__24.5-27.5 - Depth 40' Filler Material i Depth #3 Sand .� TYPE OF SEPTIC WORK: NEW INSTALLATION L7 REPAIRIAOOITiON L1 DESTRUCTION M lNo septic system permitted if public sewer is available within 200 feet.1 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line �- LEACHING LINE C1 No. 8 Length of lines Total length/site FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Sire 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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature canifies 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 applicant cal for quired inspections. Complete drawing on reverse side. } Signed Title. �- �� ` Date: �'- FOR DEPARTMENT USE ONLY Application Accepted by Date A— + Plt or Gout Inspection by Date 2 3 Final Inspection by Date 1 f Additional Comments: Applicant - Return all copies to. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL, HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 88201 FEE INFO AMOUNT DUE AMOUNT rtEMrTTEO CASH E I ED BY D`A,TE��yy PERMIT'NO, . FH 14.2 I11EV,I/AW �.� W.� /1 lV_q1 FH 426