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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468=-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUM (Complete in Triplicate) Application its 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 Joaquin County Public Health Services. Job Address �� ' rem City Lot Size/Acreage Owner's Name ,�'/ �1�/G ��i�l�i✓ -- - Address 1�vp� /G. O�. /3� Phone r _b 6� �'�- Western Strata Exploration P.O.P.O.;Bow Contractor y' �-- r Address West.=Sacramen t1J,Ca. License No. 552198 Phone 373-1118 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well C7 PUMP INSTALLATION C] SYSTEM REPAIR ❑ OT ER Monitoring Well L� �� So�T--;;r DISTANCE TO NEAREST: SEPTIC TANK W'lam---- SEWER LINES S QISPO ;AL FLD. PROP- LINE ��+C'«v,¢� FOUNDATION ' 450 AGRICULTURE WELL OTHER WELL �� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing iV O C-�'Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing 16,114Specifications (� 1"1 Public N""Other f-I Delta Depth of Grout Seal _ 24e �F Type of Grout-- I rout I I Irrioation ZLO_?SApprox. Depth I I Eastern Surface-Seal Installed by tN�71 {A Repair Work Done 0 Type of Pump N.4H.P. _ &�! State Work Done Well Destruction O Well Diameter 8 Sealing Material b Depth _ �f/�.4 _ V Depth 20 f"f Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is - available within 200 feat.I 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 ❑ Type/Mfg: Capacity No. Compartments \\ PKG, TREATMENT PLT. ❑ I Method of Disposal \ Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth t Size Number SUMPS Cl Distance to nearest: Well Foundation Property-Line t" 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 s: 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 subcontracting 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." I The applicant call for squired i ctions. Co to drawing on rev side. Signed Title: Date: i OR DEPARTMENT USE ONLY Application Accepted by Date �� Area r" Pit or Grout Inspection by a Final Inspection by Date I€ Additional Comments: t /(f 1 f Applicant - Return all copies to: San Joaquirljo=ty Public Heal �( _ Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE 1 I AMOUNT REMITTED CASH KA RE EIVED BY DATE ]PERMIT NO, i a EH 13-2�IREY.r/K 51 V�r �� ?6�7 —/ 71' EH 24.29 Vvv ff f+ I ( ! !!