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APPLICATION FOR PERMIT SAN ..,iQU IN COUNTY PUBLIC HEALTH ;:V I CES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Joaquin County Public Health Services. 'I / /� I Job Address 2_q06_2_q06_ West Be-01'a m/h t70 /T De. City StOCK7LDkl Lot Size/Acreage Ghcyron Owner's Name Produets Address 2410 Camino Ronloti Phone S10 FgV9SC> Contractor J�Oi�S IDr�tnOM, w(LtAddress '� D �95 TZ License No.C57SS 16 Phone 707 4r2928r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK Vaoli"148 SEWER LINES NQ DISPOSAL FLO._WA PROP. LINEO2S- 4- FOUNDATION 7.5 AGRICULTURE WELL NA OTHER WELL 254 -- PITS/SUMPS—t' INTENDED USE X/A TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial O Open Bottom O Manteca Dia. of Well Excavation 8,A. Dia. of Well Casing 2,n. Cl Domestic/Private ❑ GGrravel Pack O Tracy Type of Casing5ch,4D PYL Specifications Il Public f:YOther n Delta Depth of Grout Seal Jr�'. Type of Grout a ar'td 18efthAi I I Irrigation 2Sf Approx. Depth I I Eastern Surface Seal Installed by Dr;llc e Repair Work Done U Type of Pump NA H.P. NR State Work Done _ Well Destruction O Well Diameter N A Sealing Material i Depth Poef��{ Depth N& Piller Material i Depth-93 sand ,N/ 2-0R• TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No se tic syste permitted if public sewer is d availa�within, ) feet.) Installation will serve: Residence_ Commercial_ Other � — `l// Number of living units: Number of bedrooms Character of sod 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 —4 LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 hereby certify that 1 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 Horne 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." TheYnAccept*d t call fo r ins w�t�on ¢o et drawing on reverse aside. / Sig r �G Title: s tT 1�o�4/S>` Date: 0 3 FOR DEPARTMENT USE ONLY / Appliby Date • �f3 S Z) Area Pit or Grout Inspection by Date Final Inspection by CON.,pps?,rryn Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services qZLQZME Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By GATE PERMIT'NO. EH 13-24 IItEV.iins1 ,t- EH a! 611D. 7 603335