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i APPLICATION FOR PERMIT SAN JOAQU IN COUNTY PUBLIC HEALTH SERVICES j j,u7 ENVIRONMENTAL HEALTH DIVISION 1.601 E. HAZEL TON AVE. PHONE (209)468-3 r P O BOX 2009, STOCKTON, CA 95201 RES 1 YEAR FROM DA i UN 2 1 1990 (Complete in Triplicate) l ed. This Application is hereby made to San Joaquin County for a permit to construct and/or install" ions of San I application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the ��!-` �O Joaquin County Public Health Services. 1!1 a -91 East Thomsen Road City Latter Lot Size/Acreage Il Job Address - Raymond M. Quaresma Address 26290 South Union. Road Phone 209-823-1455 Owner s Name an ec a, i Contractor Westex Address P.O. BOX 1664 W.SaC License No.5-5219-8—Phone bN TYPE OF WELL/PUMP: NEW WELL ❑ .- WELL REPLACEMENT C1 DESTR{U�CT,ION Ll J Out of Service. Wel PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ S"t� T]�HER Monitoring Well �� p� ` fee N� 00 feet E y-100 .f(Pi . LINEZ'10 feet � -r DISTANCE TO NEAREST: SEPTIC TANK!100 EWER LI Sl DISPOSAL F 'n FOUNDATION>100 feeKGRICULTURE wEL1100 f-tOTHER WEL L.WLft PITS/SUMPS` 1U feet " 5 { j INTENDED USE TYPE OF WELL- PROBLEM AREA CONSTRUCTION SPECIFICATIONS- n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type of Casing Specifications j is Domestic/Private ❑ Gravel Pack E3 Tracy Type of Grout ' I"I Public ��Other • n Delta Depth at Grout Seal i I I Irrigation —.Approx. Depth 1 I Eastern Surface Seal Installed by 5011 Borings r Repair Work Done ❑ Type of Pump H.P. State Work Done _Soil — k Sealing Material & Depth „C frnm : ntal depth to surf e Well Destruction 0 Well Diameter Depth Filler Materiel & Depth gra TYPE OF SEPTIC WORK: NEW INSTALLATION system permitted if public sewer is LATION I I REPAIRIADDITION I I DESTRUCTION l 1 (No sap 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 F SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Lina SEEPAGE PITS 11 Depth Size Number SUMPS LI 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, state 18ws, 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must tali for all required inspections. Complete drawing on reverse side. r/_"� 1 //�O Signed X ✓ — Title: �E.rao S�u�� (re.cl 1 Date: - — Lt/Qllsce-,�a� Cr LC�EsTE FO A N7 USE ONLY Application Accepted by Date D Area ( Date Pit or Grout Inspection by date Final Inspection by Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK I GASH RECEIVED BY DATE PERMIT NO. INFO el ♦ EH 13.24(REV.t/n5i 3 �. -�(Q.b - 4 ��^"�7b + EH:42b