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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION A A e0 SIN, PHONE (209)468-3420 STOCKTON , CA 9'52� c� �� ✓ �� z�L PERMIT EXPIRES 1 YEAR FROM DATE ISSUED o WJLJb, N �- (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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San .3osquin County Public Health Services. Job Address 1721 West Yosemite Avenue Manteca, C�1 City _ of Size/Acreage 2.43 acres rl It -nae I Dean c/o /cD N. ria In Street, Owner's Name Central Valley Title Address _Manteca, CA 95336 P (209)995-212 23762 Foley Street, Suite 7 Contractor Vironex, Inc. Address Hayward, CA 94545 License NIC57-70592;hone(510)266-0 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n So i 1 DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ B o r i n g s OTHER)CX ( 8 ) Monitoring Well O 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 D Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2 i n C h Cl Domestic/ Private ❑ Gravel Pack SO i 1 O Tracy Type of Casing_ Specifications Il Public )(kOther B o r i n g Sl Delta Depth of Grout Seal Type of Grout I I Irrigation 2 0 f b4S Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION 11(No septic system permitted if public sewer is \ available within 200 feet.) 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 1=) Distance to nearest: Well Founaation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O hemi... -4 . •M..• 1 L-..- - . • - ----- rr --•-•• -••� •••�• • "w," .,,,, Uo uuTIn rn accuruance wltn ban 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 must call for all required inspections. Complete drawing on reverse side. Signed X 1• A� Title: Pro .i e c t M a n a g e r Date: FOR DEPARTMENT USE ONLY D Application Accepted by G+l � Date l Area PDA., (_o P, Pit or Grout Inspection by Date §11619 1 Final Inspection by Date Additional Comments: L -f �AA_�4hv rti�P� �A 4y", i --� Applicant - Ret(grn All copies to: EH 13-24 NEV. I/ n sl EH 14-2e San 7oaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 9520 FEE INFO AMOUNT DUE AMOUNT REMITTED C CASH RECEIVED BY PERMIT-NO. �Eff _ql fit - s �-Ly3 'age l3A