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APPLICATION J SAk,� OAQUIN COUNTY PUBLIC HEAL T� '�gVICES , ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (1209)468-3420 P O BOX 2009, STOCgTON9' CA 95201 I ES 1 YEAR FROM- DATE IgSUED (Complete in Triplicate) Application is hereby toade,to Ban Joaquin county for a permit to construct and/or install the work herein described. This application in made in compliance with Ban Joaquin C Joaquin County Public Health Services. ounty Ordinance no, 59 and 1862 and the Rules and Regulations of San Job Address 501 E. Acacia Street Cit T=acy Y Lot Sire/Acreage Fortifiber Corporation iff Owners Name William Rieger Address 501 E. AcacialStreet Phone 209-835-0353 i Contractor B&F DrillingAddress 3663 Omee Circle #8 License No. 519428 Phone 916-631-9546 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ® Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR 0OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _11 DISPOSAL FLO. POOP. LINE FOUNDATION_ AGRICULTURE WELL !�DTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Sol Dia. of Well Casing 2" Pq Domestic/Private 139 Gravel Pack M Tracy Type of Casing—I, PVC i Specifications I'1 Public Cl Other 1-1 Delta Depth at Grout Seat Type of Gross I I Irrigation 20'�Approx, Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. 1� State Work Done_ Well Destruction ® Well Diameter Sealing Material i Depthit Neat grout: 0' to, 20 1 Depth Filler Naterial i Depth I� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewei is Installation will serve: Residence— Commavailable within 200 leat.lercial— Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity I No, Compartrnsnts PKG, TREATMENT PLT.Q Method of Disposal Distance to nearest: Well Foundation Property Lina I� LEACHING LINE 0 No. 8 Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line I� SEEPAGE PITS 11 Depth Sire -' ~um yr ' SUMPS Ll Distance to nearest: Well Foundation IProperty Line ..I.,POSA�?OWOS�'❑ ..,.�,.�� --a��.,:T•'�'ti�-� 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-conttacting 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 compenso- lion laws of Califomis." The applicant must call for required inspsGtions. Complete drawing on reverse side. Signed _�. Sv'�(, Title: Supervisor, Geosciences 11/9/93 Date: FOR DEPARTMENT USE ONLY Application Accepted by %J4,1A 6-1/1 . 111116tW Area Pit or Grout Inspection by Data /l/16hZIFinal Inspection by � FD ts'' , Comments: 'I Addition*] Commsn : a�. 4 p�,,r .L+1 + � � + jl �a Applicant - Re urn all copAs to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2005, Stkn, OA 85201 �I FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY INFO C 3 DATE PERMIT N0. • EN 13.24 1XEV.1 i n 6f i EM 71.70 ,