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lr I s o ct APPLICATION FOR PE MIT t 36 SANY AQUIN COUNTY PUBLIC HEALTH 4.1VICES ENVIRONMENTAL HEALTH DIVISI ON V 445 N SAN JOAQUIN, PHONE (209)468-3420 } P O BOX 2009, STOCKTON, CA 95201 B i PERMIT EXPIRES 1 Y FROM D TE,� SU j� (Complete in Triplicate) e; Fr, Applic , ation 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 vith San Joaquin county Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaqu�n County Public Health Services. JobAdidress 16 $ Street City S+1r-1r-4—,k loot Size/Acreage ? JCS i� Owner'I Name ._Qaltrans -_- Address ikton Phone( - Valley Well. Drilling CA 9;5201 Contract�� apoccr,rg AddressPOBOx897, Glendora ] 'License No.(- Phone — 29 r� u A TYPE Of WELT./PUMP: NEW WELL ❑ WELL REPLACEMENT (7 .DESTRUCTION ❑ Out Wei PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well _DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LI see attached Hca FOUNDATION T �= AGRICULTURE WELL OTHER WELLY=+ `PITS/SUMPS�" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial .- ❑ Open Bottom ❑ Manteca Dia. of Welk Excavation ti"�Rhe Dia. of Well Casing ++ r � =' r� L1 Gravel Pack C3 Tracy Type of Casing_ Pyr Speci(icatans a �ra•.r; .- � ` 1'1 Public s Othe%sandpaeP, Delta Depth of Grout Seal s awing Type of Grout r,PmPnt I I Irrigal�ion S C't.�Approx. Depth I I Eastern Surface Saul Installed by^^ :r 11 Repair Work Done L] Type of Pump N/A H.P. Stats Work Done_ Well Destruction II ❑ Wall Diameter '411 Sealing Material L Depthng Depth 601 -801 filler Material i Depthmt7nt2rey, sand#3/see drawing TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION i I DESTRUCTION I 1 JNo septic system permitted i1 public sewer is N/A vailable within 200 feet.) Installation will serve: Residence_____ Commercial_ Other Number of living units: Number of bedrooms 10. Character of sou to a depth of 3 fast: , {- Water table depth SEPTIC,JTANK ❑ {Type/Mfg - f Capacity 11No. Compartments + PKG. TREATMENT PLT.❑ `` i!I M�p1��d of Disposal Distance to nearest: Well Foundation Property IRBtyM LEACHING LINE, ❑ No. 3 Length of lines Total length/sib FILTER BED -0 Distance to nearest. Well Foundation P, rty V* JOA tel SEEPAdE PITS It Depth Size NuLft LTH SER SUMPS' Ll Distance to nearest: Well Foundationg AProperty +ns L� DIVISION DISPOSAL PONDS .❑�. I herebyllcertify 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 I II 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 dalifomia." Contractor's hiring or sub-contracting signature certifies ihs 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." r The applicant musts lWetL �inspections. Complete drawing on reverse side. Ii Signed Title: PROJECT DIRECTOR Date: 10-01-93 OR DEPARTMENT USE ONLY A licatlon Accepted � p pP ep b �y , 2..._ Date ` Area Z113� Pit or Gr wt Inspection by Date Final Inspection by Addnionil Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CAK RECEIVED BY DATE PERMIT'NO. • EH 13-24I11EV.+'VKal "4 EH i4•�a ✓ � t� � G� � I ! �y