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APPLICATION 11 T� �• SAI1I ,OAQUIN COUNTY PUBLIC AFAT.T" ERVICES ` ENVIRONMENTAL HEALTH DIV • 445 N SAN JOAQUIN, PHONE (.209 468-3 � r P 0 BOX 2009, STOCKTON, CA 95201 # MITI PERMIT EXPIRES 1 YEAR FROM�.D EISSUED #OVA {Complete in TripliG )'_ Q�bApplication in hereby made to San Joaquin County for a permit to construct 11 o '1 psi e Th application in made in compliance with San Joaquin County Ordinance No. 549 a 1862 and the Rules and RegulaticsSa Joaquin County Public Health Services. II Caltrans/1603 Southr "B" Street Job Address City StlBeckton Lot Size/Acreage Caltxansia e^t, o� M�i4+ 1936 E. Charte`> Wayl� Stockton Phone =e) Owner's N me 4ddress MCalifornia Department of Transportation) W. Sacramento Westex P,O. Box 1664 r 1Contractor Address , �CZ S9.5691C1r1`-se No,C-57 S52198p - 8 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well f' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES dISPOSAL FLD. PROP. LINE ! -- - �...�..�-ti ;._ F,S..OSAL ,.. _ , ,_ � � FOUNDATION "' AGRICULTURE-WELLOTHER'WELL ' _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F-} Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ii Dia. of Well Casing F1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications r I'I Public Cl Other Ll Delta Depth of Grout Seal I� Type of Grout I i Irrigation _Approx. Depth I I Eastern Surface Sedi Installed by Repair Work Done U Type of Pump H.P. 11 State work Done, Well Destruction ❑ Well Diameter Sealing Material i Depth 9I' }� Depth Filler Material i Depth l ;i 3 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I aijjpp system permitted if public sewer is PA II+vithin 200 feet.) Installation will serve: Residence.____ Commercial_ Other ��/C D ` Number of living units: Number of bedrooms ,l 3 E Character of soil to a depth of 3 feet: _ .AY �' Olt table depth SEPTIC TANK ❑ Type/Mfg Cspacity�IN rtrr►enta PKG. TREATMENT PLT. 0 Pl1�I.Ml�1�EALTIA NO fJ"��3oaal A�l1. ,pp Distance to nearest: Wel! Foundati NT r1'R Line LEACHING LINE Ll No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation I� Property Lina 4 SEEPAGE PITS I I Depth Size 'INumber I SUMPS_ _ yLlr Distance [o nearest Well �Fpundation.___, i __ :. ,mneme Linte DISPOSAL PONDS ❑'r W a ., 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 1bb . ?� Home owner or licensed agent's signature certifies the following: "i certify that in the pedormlance 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." i y1 The applicantat t e11 r all requir n ctions. Complete drawing on reverse side. t� !I Signed Title: $ t d .,.,.1 6 MA11��Date: J41 1 7 , 1 I q OR DEPARTMENT USE ONLYIi 141 Application Accepted by Date Area Pit or Grout Ins d t pection by Date Final Inspection by 1 Additions! Comments: Applicant - Return all copies to: San Joaquin County Public Health services P[ j Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009,FEE Stkn, GA 95201 li !� INFO AMOUNT DUE AMOUNT REEMyI/T�TED CASH RECEWED BY � DATE PERMIT'ND. • Eli 13-24 iREY.�i x 5! � - V"' Page 134 I