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APPLICATION FOR PERMIT e SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ' � ENVIRONMENTAL HEALTH DIVISION bti5- 10 445 N SAN JOAQUIN, PHONE (209)468-3420 Loi -111) of-11 P 0 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 with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 9733 PRIEST RD.- City FRENCH CAMP Got Size/Acreage 2 ACRES Owner's Name RALPH WILLIAMS Address 9711 PRIEST RD. Phone 477-5963 Contractor HENNINGS BROS. DRILL.Address 3525 PELANDALE MOD 9535�icense No. 290813 Phone545-1185 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT E1 DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6 11 N Domestic/Private. b(Gravel Pack 0 Tracy Type of Casing_ P V C Specifications-.1 6 0 S C h I'1 Public Ell Other n Delta Depth of Grout Seal 100 , Type of Grout BENTONITE I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by H E N N I N G S BROS. DRILLING CO. Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material A Depth Depth )filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted it public sewer 1s available within 200 feet.) 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.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest. Well Foundation Property Line SEEPAGE PITS l 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ I hereby certify that I have prepared this applicatiomand that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 worst for which this permit is issued, I shall employ persons subject to workman's compensa- tion Iowa of California." The applicant must call for of required inspections. Complete drawing on reverse side, Signed >L A ��*tle: Date: MAY 18, 1993 A!. _ F DEPA TMENT USE ONLY (� (� Application Accepted by _T ,6/ I S Date !—�� Area T�.,_„+L�,L'_`•C'” Pit or Grout Inspection by Data Final Inspection by MAJIL Date Additional Comments: qyou Oil- 6&0, Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Healtb Permit/Services 445 R San Joaquin, P O Box 2009, Stkn, CA 95201 FOE IN O AMOUNT DUE �!A/M'pUNT REMITTED K ECEIVED BY DATE PER/M�iT'NO . V 13.24 111EV.I/A 5! a 1 / �( - EH 14.26 [ d