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APPLICATION - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQU-IN, P11ONE (209)468-3420 P O 13O% 2009, STOCKTON, CA 95201 PERMIT EgPIRES 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. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public health Services. 7166 Job Address tiBrlaella Road City Victor Lot Size/Acreage 1001 X 1001 Owner's Name County of San Joaquin Address P. 0. Box 1$10 Phone (209) 468-3000 Maggiora Bros. 595 Airport Blvd. ' Contractor Drilling, Inc. Address 'Ratsonville CA 95076 (408) 724-1338 License No. 249957 Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION .D Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well . DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES NIA DISPOSAL FLD. NIA PROP. LINE 20" 0111 FOUNDATION N `� AGRICULTURE WELL N A OTHER WELL 8001 PITS/SUMPS N- A r� _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing 611 D Domestic/Private 30 Gravel Pack ❑ Trac T Steel y ype of Casing_ SpecificationsAS7M A-53 , I'1 Public Ci Other n Delta Depth of Grout Seal To be determinf4e of Grout 10 sack I I lrrioation T.•. Approx. Depth I 1 Eastern Surface Seal Installed by Maggiora Bros. Drilling, Tnc. Repair Work Done U Type of Pump H.P. State Work Done Welt Destruction ❑ Well Diameter Sealing Material & Depth A. Depth Filler Material & Depth TYPE Of SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I i iNo septic system permitted it public sewer is available within 200 feet.1 T Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms PA y41,eiy Character of soil to a depth of 3 feet: ��f SEPTIC TANK ❑ Type/Mfg Capacity A"C PKG, TREATMENT PLT. ❑ ItAp Distance to nearest: Well FoundationReosq ,jQJ �! FN IJ HIE LT TY LEACHING LINE CI No. & Length of linesTotal length/size HEAL FILTER BED C1 Distance to nearest; Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS h7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 e- rules and regulations of-the San Joaquin County - ' - � _ �_ �--..- Home owner or licensed agent's signature certifies the followings "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 Celifornia." 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'applicant must callall d lnspa 'ons. Complete drawing on reverse side. -Signed Title: Contract Administrator Date: 02-02-93 F R D ARTMENT USE ONLY Application Accepted by el Date Area Pit or G ut nspection by Date Final Inspedtio .by Date t. v Additional Comments: Applicant - Return all cop es to: Sa Joaquin County Public Health Services Environmental Health Permit/Services .C�, 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. A INFO ,ter J • l:H 13.4 (REV.i/as) -� � plot ( �f -12 (