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APPLICATION FOR PERMIT SAN JOAENV ONMENTAL HECY LALTH D IC I VT S ON VICES 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 JUL 1 i pERMIT EXPIRES 1 YEAR FROM DATE ISSUM NViRONMENTAI REWL-TP f115- (Complete in Triplicate) n nAAlTjl�cp�Of c' Application is hereby rnade.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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /,? 4,—2-&D— k)' Jab Address 9 East Thomsen Road City Lot Size/Acreage q arreS _ 26290 South Union Rd. Man &hone - ' Owner's Name Raymond M. Qua�esma Address West 1 Contractor WESTEX Address P-0- Box 1664 Sacramenl0ense No.C57-552]98 Phone9 - - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LIOut of Service Well ❑ Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 5J50 rr_ DISTANCE TO NEAREST: SEPTIC TANK 7 _LQQ^- SEWER LINES 7 100 DISPOSAL FLD. 7 100 PROP• LINE 7 U Y] FOUNDATION 7 100 -- AGRICULTURE WELL 7100 OTHER WELT '? PITS/SUMPS 7�0 I I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS // fi C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation to Dia. of Well Casing " " T e of CasingSpecifications D Domestic/Private ❑ Gravel Pack ❑ Tracy yP I'] Public I"1 Other n Delta Depth of Grout Seal 2fl Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction El Well Material & Depth Well Diameter Bentonite/Cement Depth Filler Material &Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septticsyst m permitted if public sewer is available whinInstallation will serve: Residence_ Commercial_____ Other Number of living units: Number of bedrooms _ .» Character of soik to a depth of 3 feet: Water table depth - SEPTIC TANK. D Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal 'Distance to nearest: Well Foundation Property Line I Total ten th/size i LEACHING LINE L1 No. & Length of lines g FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number j SUMPS CI 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 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 subcontracting signature conifles 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 requirespections. Complete drawing on reverse side. /C / �t?r.,`Or GCe - if Dere: -7/'Z y �yy _ Signed Y Title: J IK r { FO USE ONLY Application Accepted by Date f� 9 flDate Final Inspection by Date Pit or Grout Inspection by Additional Comments: Applicant - Return all copies to, San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 S. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 �.r! INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. 4I IPH 1124 tREVsl $ .r ''1`H;4.29