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APPLICATION FOR PERMIT SAN J"OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOIL 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YS63 F01�dT� ISUM (Complete in Triplicate) Application is hereby made,to Ban Joaquin County for a permit to construct and/or install the work herein described. This application 1s made in evn>plianee V1th Elan Joaquin County Ordinance No. 549 and 1862 and the Rules and Reeulationa of San Joaquin County Public Health Services. Job Address 17750 Fast Highway 4 City S�oD k� Lot Size/Acreage Owners Name Arnold Souza Address 17750 East Highway 4 Phone 9no-941-851 S Convacto(Cache Creek Drilling Address P.O. Box 999. Wood)anti License No. 57ME"I Phon91 - - TYPE OF WELL/PUMP. NEW WELL 0 WELL REPLACEMENT Cl OESTRUCTIO-N3g Out of Service Hell 0 PUMP INSTALLATION 0 SYSTEM REPAIR Ll OTHER 43 // nn*ijopt-,lrnng,g Well •rn DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. L E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ..-- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial C Open Bottom 0 Manteca Die. of Welt Excavation T Pia. or Wall Casino �� f rl Domestic/private 0 Gfaval Pack 0 Tracy Type of Casing_ Specincellons I'I Public I.1 Oihar 1`1 Delta Depth of Grout Seal Type of Grout I Inigallon _—.Approx. Depth I I Easlem Surface Saul Installed by Repair Work Done 0 Type of Pump WP. to Wgrk pone _ Wall Destruction ❑ Well Diameter Sealing Raterial i Depth �ack cement Depth Filler Notarial i Depth 3 g — — WRK TYPE OF SEPTIC O : NEW INSTALLATION 1 REPAIR/AOOITION I I DESTRUCTION I I INo septic sysruni permitted it pubic sower is available within 200 feet.) Installation will serve: Residence_, Commercial— Other Number of living units: Number of badroomt Character of soil 10 a depth of 9 feel: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. rJ Method of Disposal Distance to nearest: Well Foundation Properly Line LEACHING LINE 0 No. b Length of lines _ Total length/size FILTER BED 1-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS LI Distance to neatest: Well Foundation ., Property Line DISPOSAL PONDS (l I hereby certify that I have Pfeparad this applicarlpn and Chet the Work will be done in accordance with San Joaquin county ordinance,, slate laws, and rules and regulations of the San Joaquin county Home Owner or licensed agent's signature cenifias the following: "I cenify that in the performance of the work for which this permit is issued, I shall not employ any person in such rmnnar as to become subject to workmen's compensalion laws of Cellfcfnia." Contractor's hiring or sub-convecting signature tertif 11 the following: "I cenify That in the performance of the work for which this permit is issued, I shell employ persons subject to workman's compensa tion laws of California." Thea lice Mu 11 for all required inspections. Complete drawing on reverse aide. Signedp NI u�U� Title; President Date: 4/9/90 FOR DEPARTMENT USE ONLY Application Accepted by "K Date Argo '211 Ph or Grout Inspection by / Date Final Inspecuo py `��f'��zl�!_—� Date / %n Additional Comments:/Z i!� n �Cll � Nv (J �ryre!' c CJ//vi e/d /L/-PlS ApplScent Return all copies to: Ban Joaquiq County Public Health Servicee, Environmental Health Permit/Services i/✓ (,/j� � ./sy�G / J'W�� L r ,J - 1601 E. Hazelton Ave„ P 0 Box 2009, Stockton, CA 95201 7 J�f'Lf— FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED By OATF PERMIT'N0. r !M 44(REV.tie Dl ��d't/ _ 3SBv �2a'