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APPLICATION FOR PERMIT 3 l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Ey ENVIRONMENTAL HEALTH DIVISION a P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 J!EMIT EXPIRES 1 JEALft PRQM DATE ISSUED 1 (Complete in Triplicate) Application is hereby trade to San Joaquin County for a"permit to construct and/or install the work herein described. This application is made in cempliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 2061 S. I ilgR-cm City Rkn Lot Size/Acreage 118 ac/te ra2�hcein [3�a� 1701 0 Ranch, S.te D 473-1106 Owner's Name Address Phone UujLk Wett,u Inc 2024 £. Chantel flay 271560 462-7676 Contractor Address License No. Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTIOb*JZWut of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 / 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 n Industrial O Open-Bottom ❑ Manteca Die. of Well Excavation Dia, of Well Casing [J,Oomest ic/Private 0 Gravel Pack n Tracy Type of Casing Specifications j M Public 171 Other 0 Delta Depth of Grout Seal Type of Grout a IriiUatio6 App(ox, Depth Cl Eastern Surface Seal Installed by (� � Repair Work Done U Type of Pump H.P. State Work Done _ XJ Well Destruction O Well Diameter 6 n Sealing Material lG Depth 41 , .I Depth _ 41 , Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIRIADDITION 0 DESTRUCTION CJ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other { J} Number of living units: _., Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthtsize FILTER BED C') Distance to nearest: Wall Foundation Property Line SEEPAGE PITS I I Depth Size NumberI' SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 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 s all f ell r i ed s ct' Co I a drawing on reverse side: Signed Title-Ua zk 61e.9_9, . Inc. Date: 5 ,4/z zii 41 i5 NTUSE ONLY Application Accepted by 44AA Date _. 5 Area Pit or Grout Inspection by Date Final Inspection by Dated r S `fit Additional Comments:.. 0 — Applicant - Return s11 s- copto: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES I 445 N SAN JOAQUIN, P O BOR 2009, STOCKTON, CA 85201 FEE NT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERMIT No. INFO CASH Pi � ♦ EH 13-24[REV,iIROi I EH��' J�