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I APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is.hereby made to San Joaquin County for a permit to construct and/or install the Work herein described. This application is made in conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 17100 S. {taAian Rd Cityr�}/2-n—�-- Lot Size/Acreage .35 ` Owner's Name E. R. Ca"ZpEa.tET Address PO Box 279 Phone 982-4800 r Contractor CXazk Vg_eZInc. Address 2024, C. C:hal7ip-;7- -I.lriu LicenseNo.37956C) _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTX'cx DESTRUCTIONkd2)@ut of Service Well ❑ PUMP INSTALLATIOWZx SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK �400SEWER LINES DISPOSAL FLO. PROP. LINE 1.5 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation . o Dia. Well Casing 8 s i _ 1 Fa Domestic/Private )l2iGravel Pack ❑ Tracy Type of Casing_ Specifications 4 0#.g, I'3 Public Cl Other Fl Delta Depth of Grout Seal 50 ' Type of Grout 9 Anrk O xaKfrfr Dation _.Approx. Depth I 1 Eastern Surface Seal Installed by UQZk O Repair Work Done 0 Type of Pump.-UY H,P. ^ 7 9/�_ State Work Done 920 11,2 Well Destruction ❑ Well Diameter 80 Sealing Material & Depth 4 p p }f n pj i o g; 9 , czck Depth 15 0' Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 Jeet.l 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 SEPTIC TANK. ❑ Type/Mfg _ : Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 compensa- tion laws of California." The applicant call f 11 it c ' o let drawing on reverse side. Signed x Title: V/- C-eayzk IJe,L/.ez_„Inc. Date:4 j4aU 92 F DEPAATMENT USE ONLY Application Accepted by Date Z Area ry PI r Grout I pection by rate Final Inspection b Datd1114711 Additional Comments: ir<C 1 a . Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE � I�iN,�99FO AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE(��'7 FHPERM17'NO. . E1Wh - ' . 1. 7{-Ia W 3-241AEV.rinse 1,DLGi� �� s IGr + 6,;- 0% f