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I072,cD ' APPLICATION FOR PERMIT v SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 .22MIT EXPIRES „]; YEA_R_FROM DAT, ' ISSUED (Complete is Triplicate) Application is here made to San Joaquin Count for i PP by � q y permit to construct and/or install the work herein described. This i application is made in compliance with San Joaquin County Ordi ce No. 549 and 1862 and the Rules and Regulations of San I F Joaquin County Public Health Services. LtJ{7+sr�bS pk R Job Address TR,_0 R:N_T-O.N- R_D.. S . O F $MILE R D. City S TO C KTO N Lot Size/Acreage Owner's Name TETCHERT CONST. Address P .O . BOX 1118 STOCKTON phone 945-8500 J Contractor HEIS MI CROS. DRILLING COAddress_352� PELANDALE AVE. _T License No. 290813 Phone 545-1185 ' TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well L1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK —O— SEWER LINES –0– DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 In Industrial ❑.Open Bottom ❑ Manteca Dia, of Well Excavation Dia- of Well Casing 10 F Domestic/Private XX Gravel Pack ❑ Tracy Type of Casing PVC Specifications 17 Public fa Other 1 171Delta Depth of Grout Seal S o I Type of Grout_bEtITL`1NTTF__ XI Irrigation —.Approx. Depth "I I Eastern Surfac Saul installed-by H E N N T N Iz S R R O S , [IRT 1 I T (J(= ('0 { Repan Work Done 12 Type of Pump __S_V H.p. 7 z State Work Done `Well Destruction ❑ Well Diameter Sealing teri & Depth M� ° Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I i INo septic system permitted if public Bawer is 1 available within 200 feet.) installation will serve: Residence ter- 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 f Capacity No.-Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size-- FILTER ength/size FILTER BED , ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth t Size Number SUMPS LI Distance to nearest. Well Foundation Property Line DISPOSAL PONDS ❑ I „� 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 compan - tion laws of California." The appli nt must call for all required inspsctlons. Complete drawing on reverse side. C a _ o.6> a 1 C:tJ Signed Title: 4 r4,!r � �Daite: Y 171'9 9 1 R DEPARTMENT USE ONLY Application Accepted by Date A Area l i Pit or Grout Inspection by � � �'✓�C��e 1 t Final Inspection by Date 6 �` `3 A Additional Comments: C Applicant – Return all copies to: Ban Joaquin County Public Health �Q�-- e�o� Ar Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE ' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EH t4.26A PN OD EH 13-24{REV;1/h 5) 13'f r�( � t