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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL REALTH DIVISION P O BOX 2009, STOCKTON# CA 95201 (209) 468-3W3L1,;;"0 PERM RES T YE'R 'FROM DATE ISSUED (Complete in Triplicate) tau work in application is madebincot�liance withuin SanCJoaquinor a County Ordinancermit to nstruct No. 549aando1862aand theeRules andeRegulationsdof This Joaquin County Public Health Services. Job Address 521. NORTH CHEROKEE .ANE 95240 City I ODI Lot Size/Acreage 179. lr 66 ACRES) MOHAMED �ANEEL— Address �1 rHEROKEE L0.NE,l milt, CA Phone owner's Na RANCHO CORDOVA _ �r�A�LCO�N��ENERGY AND e �j] Contractor WEST A MATDRt I TNS Address FTTELL RP n EMEN F1 Lice se No. Phone. TYPE OF WELL/ MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Well Service we-11 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ p(��OTHER X.1 GG TTII RINGS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLd.— PRCT�1TNf FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 411 (l Industrial ❑ Open Bottom ❑ Manteca Die. of Wall Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy EL OZ Type of Casing PJ'-- - 5, 1, h-16 Specifications r r-n:I C4.) '� 3i?` T of Grout C-t° dzr\T54.0 M Public zn 4^ Other , 4_ ❑ Delta Depth of Grout Seal Type A p. (('' r�� tAi;�i3 rG-u,te:t'l U trrigaoon µc��,o � rAPPro+• Depth ❑ Eastern Surface Seal Installed by Repair Work Gone ❑� Type of Pump H.P. Stat Work Donk Well Destruction ❑ Well Diameter it Crh iN iU Sealing Material i Depth '}t �-f 'l u IJ / SLR t Filler �Rrt) e: Mate:lel Depth (� ipr".{ I i ��'�9 . 4c DDepth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/AOOITION G DESTRUCTION ❑ (No septtic ihst m pe,r Wild it public sewer is Installation will serve: Residence _ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 7 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. d Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby comity 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 csnifies 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.- Convector's hiring or subcontracting 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 all required inspsaiora� m drawing on reverse side. Signed _ - Title: Date: F R DEPARTMENT USE ONLY /' Application Accepted by oats �Ll Area �.t"Ll —JZ Pit or Grout Inspection by Date Find Inspection by Dots Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CKs RECEIVED BY DATE PERMIT NO. INFO �/'c/..� Lam.[/FCA,SH ��^j�,t./,t, (� /��/ E/•/1/ ^/ / . EH 11.24 iAEV.ir•fi f ,( / U- 11 /U Z� I V •' \ —�J [ � ` ` �//� ` EN l4— t V -