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T y APPLICATION FOR PERMIT .� SANOAQUIN COUNTY PUBLIC HEALTH RVICES PAYMENT ENVIRONMENTAL::HEALTH DIVISION RECEIVED p O BOX 2009, STOCKTON, CA 95201 FEB - 1991- (209) 468-3447 SAN JOAQUIN COUNTY ilEAR PROM PATE LIUWLIC HEALTH SERVICES (Complete in Triplicate) ENVIRONMENTAL HEALTH DIVISION Application is hereby made to San Joaquin County for n permit to construct and/or install the work herein described. This application is made in co4liance with San Joaquin County Ordinance No. 549 endA862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _ _ Cit StOClG#On :;+ Lot Size/Acreage A ppr 781 Swift W v`_ owner's Name Swift Transbortatinn. ._ Addfess 781 swoft Lhl Phone 943-1476 CA 95691 Contractor WESTEX Address P_O. Box 1664, W." Sac.License No. 552198 Phone - 373-1111 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C"7 DESTRUCTION 5 Out of Service Well ❑ . M itgri well REPAIR ❑ OTHER. X pp ❑ PUMP INSTALLATION ❑ SYSTEM E $Olt t30rin S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL-.PITS/SUMPS - INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia:of Well EYc alio Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casin Specifications P_] Public M Other ❑ Delta Depth of Gro t Seal � � Type of Grout 0 Irrigation Approx. Depth D Eastern Surface Seal I d Repair Work Done U Type of Pump H.P. Stale Work pone _ Well Destruction ❑ Well Diameter Sealing Material ak Depth Neat Cement 'Grout to-Total Depth Depth Filler Mate' ial i Depth E TYPE OF SEPTIC WORK: NEW INSTALLATION.0 REPAIR/ADDITION 0 DESTRUCTION 1-J lNo septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence_ Commercial_ Other r 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. C7 Method of Disposal "Distance to nearest: WellFoundation Property Line LEACHING UNE ❑ No. 8 Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Sire Number SUMPS Ll ,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 compansaiion laws of California." Contractor's hiring or sub-contracting signature 'i 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, I tion Iowa of California." _ The applicant must call for alt requir d in coons. Complete drawing on reverse side: Signed X_1. ,Title: Pr6iect Geologist/Agent for Date: �-31-91 stex R D _ M9ENT USE ONLY r Application Accepted by Date Z''2Z^� Ara Pit or Grout Inspection by Date Final Inspection til Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC�HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PBRHIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2049, STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED 8Y ' DATE PERMIT'NO. i EM 1374{rIEV (2* L/V3� ?�/ EM t�•Za