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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIROMIENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 9711 PRIEST R D. City FRENCH CAMP Lot Size/Acreage 2. 2 ACRES Owner's Name RAYMOND D E N U I T Address 9711 S. PRIEST RD. Phone 982-5870 contractor HENNINGS EROS. DRILL-Address 3525 PELANDALE MOD 95356License No.290813 Phone545-1185 TYPE OF WELL/PUMP: NEW WELL IN WELL REPLACEMENT n DESTRUCTION 1=1 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 10 0 t SEWER LINES 100 ' DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6 tt CSV Domestic/Private Mravel Pack ❑ Tracy Type of Casing_P U C Specifications 16 0 S r h 11 Public 1:1 Other 11 Delta Depth of Grout Seal —4" 0 t //o Type of Grout BENTONITE I I Irrigation /42G-Approx. Depth I I Eastern Surface Seal Installed by H E N N I NGS BROS. DRILLING CT. Repair Work Done U Type of Pump H.P. State Work Done T Well Destruction ❑ Wall Diameter Sealing Material i Depth Depth filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soN to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity--- No. Compartments PKG. TREATMENT PLT.C1 Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE C1 No. & Length of lines Total lengthtsize FILTER BED ❑ Distance to nearest: Well Foundation Properly Line SEEPAGE PITS l I Depth Size Number t SUMPS L1 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, slate 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 Calif ornis." 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 call for MI required inspections. Complete drawing on reverse aide. Signed X F� 4 ntl3ylAn�tsr �1�- - L_r1W le: Date. MAY 18 �. 1993 FOR DEPA TMENT USE ONLY I' Application Accepted by A.a� ' i _., .. 1r..,__. Date rea 82 Pit or(�Inspeetlon by Date Final Inspection b Data Additional Comments: ni / 'F / 1 S� _4 ! ' Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED K CEIVED BY DATE PEW MIT'NO. • EM112 iREV.s i K si �7. 07 EM 11.26