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a <br /> - Sf <br /> ~�~ APPLICATION FOR PER1dI,, <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES : -> V :vi•t+." <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> 1601 E.''SAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 L <br /> PERJIIT EXPMES_1 YEAR FROM 12ATE ISSUED <br /> (Compl(ite 'in Triplickte) rNVIRONMENTAL HtA.T!' <br /> ,­1AfIT1rrnv1rr- <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County OrdirL&hce No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _41- East-Thomsen Rnad ' ,� City Got Size/Acreage 3 acres <br /> Owner's Name Raymond M. Quaresma . Address 26290 South Union Rd_ ManteCZPhone 209-823-1455 <br /> West <br /> - - <br /> West <br /> Contractor WESTEX Address P.O. Box 1664 SacramenjWnse NoC57-55298 Phone9fi-373-1 119 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 2.A00_- SEWER LINES ? 100 DISPOSAL FLD. > 100 PROP. LINE <br /> FOUNDATION Z-1-00 , AGRICULTURE WELL —1.04 OTHER WELL 7 1,QQ_ PITS/SUMPS Z_U0 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4- <br /> C] Industrial 0 Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> 1'1 Public I:1 Other {"I"Delta Depth of Grout Seal 2� Type of Grout �� <br /> I I Irrigation _.Approx. Depth 11 Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth Bentonite/Cement <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence.,...... Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth - {� <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 'Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No, 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin County <br /> 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, t shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> canities the following: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complate"drawing on reverse side. <br /> Signed X, Title' Date: <br /> 5"? l fsr FF {c a .`r� <br /> _ Ft] _,"T �USONLY <br /> Application Accepted by Date -- <br /> Pit or Grout Inspection by DateFinal Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Elan Joaquin County Public Health <br /> Services, Envirbtumental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY OATS PERMI7'iVO, k ` <br /> WRIV <br /> . • EN t1.�p fREV.rr:rsl jf b <br />