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APPLICATION FOR PER:dIT SYJOAQUIN COUNTY PUBLIC 1 EALTH RVICES ZNVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 i R -Y R R L)AT5 ISSUED (Complete `iu Triplicate) Application is hereby arade.to San Joaquin County for a permit to construct,and/or install the work herein described. This application is made in coWliartce with San Joaquin County Ordinance No. 549 and 1862 and the Rules a.tsd Regulations of Sart Joaquin County Public Yealth Services. Stockton r_ .lob Address _ 781 SwiftWav -- - City-- — �. Lot Size/Acreage Atnrrnrnv L—nt- Owner's Name Swift Trad5ortation __ Address Phone 943-1476 CA 95691 Contractor WESTEX Address P.O. BOX 1664, SaC,License No. 552198 Phone 91 L373-1 11 T_YPE - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Ll Out of Service Well 0 PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER '�SOIIMCSO onSSrell C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES y DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELT. PROBLEM AREA CONSTRUCTION SPECIFICATIONS U1 Industrial °'❑ Open Bottom ❑ Manteca Die. of Well Excavalion Dia. of Well Casing Cl Domestic/Private 0 Gravel Pack G Tracy Type of Casing Specifications ❑ P,IbGc 11 Other C Delta Depth of Grout Seal type of Grout 1. CJ Irrigation Approx. Depth G Eastern Sutfacs Soul Installed by J Heoeir Work Done L7 Type of Pump N.P. State Work Done _ Well Destruction O Well Diameter Sealing Hateri" i Depth Neat Cement—Grout to Total Depth Deorh Tiller Materiel 0 Depth TYPE OF SEPTIC WORK:' NEW INSTALLATION❑ REPAIRrADOITION C DESTRUCTION Ci (No septic system permitted if,public sewer is available within 200 Iset.f Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of wit to a depth of 3 feet: Water table depth SEPTIC TANK p Type/Mfg Capacity No. Cornpartments PKG. TREATMENT PLT, C1 Method of Disposal Distance to nearest: Well Foundation Property Line . LEACHING LINE C1 No. S Length of lines Total length/elle FILTER BED ❑ Distance to nearest, Well Foundation Property Line SEEPAGE PITS I 1 Oeoth Sire Number SUMPS L1 Distance to nearest: Well Foundation .Property Lina 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: "t certify ahaf in the performance of 1he work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmen's compensation laws of California,"Contractor's hiring or sub-contrecting 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 Califarnia." The applicant must call for all wired inuiections. Complete drawing on reverse side. Signed X_ Title: Project Engineer /Agent dor Date:. August S. IgQt ' DavidR. Gi Westex FOR DEPA T US' Q y °.. Application Accepted by Date _ Area Pit or Grout Inspection byDate 4 inel Inspection by_ Date�_. Additional Comments: Applicant — Return all copies :o: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES U J T ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 952 INiO AMOtJNT OUE ,mouNr AEMITTED CASHRECOVE0 a ' DATE PEAM17'NO, H O D - E :�.� � � O �f r .. -- 1 i ;i