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- lM j APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYIVfNT ENVIRONMENTAL HEALTH DIVISION RECEIVED P 0 BOX 2009, STOCKTON, CA 95201 F E B - R 19al (209) 468-3447. SAN JOAQUIN COUNTY PERMIT EMIRRS I YZAR EROM PAJE 15SUMBLIC HEALTH SERVICES (Complete in Triplicate) ENVIRONMENTAL HEALTHDIVIS10N Application in hereby made•to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coerpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Jab Address 781 Swift ?Wim __ City:S.tOCktOn .--` Lot Size/Acreage Anne r_OX 1-21C Owner's Name Swift Transportation Address 791 Swift junw Phone 943-1476 a CA 95691 Contractor WESTEX Address P.-O._ Box 1664— W. _Sao;License No. 552198 Phone 916-373-31 TYPE — — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 _DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER INSOilMC5Qtr1�I� S�e11 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PF108LEM AREA CONSTRUCTION SPECIFICATIONScg f F1 Industrial © Open Bottom ❑ Manteca Dia. of'Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing .Specifications M Public I'l Other ❑ Delta Depth of Grout Seat Type of Grout 0 Irrioation _Approx. Depth ❑ Eastern Surface Seat Installed by " Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction D Well Diameter Sealing Material i Depth Neat Cement Grout tQTotal Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION CI. DESTRUCTION ❑ (No septic system permitted if public sewer is ii�vajlaKe within 200 fest.1 Installation will serve: Residence __ Commercial_ Other Number of living units: Number of bedrooms / r Character of soil to a depth of 3 feet: O atar table depth SEPTIC TANK ❑ Type/Mfg CI&Sc y No. Compartments t/ PKG. TREATMENT PLT. C1 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 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 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 shail employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required in ctions. Complete drawing on reverse side. Signed X. Title, PrOieCt Geologist/A. ant for Dace: 1-31-91 a �PcfG ��C3QglL� I: ester R D . MENT USE'ONLY Application Accepted by Date ^ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STUCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT fi/EyM�I;TTE(({y)�� ' __CKSH RECEIVEb BY I DATE PERMIT'NO. . O EN 1 .21 111EY.r/M 3)