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APPLICATION f-3 SAN JUAQUIN COUNTY PUBLIC HEM TiDVtwo f�� ENVIRONMENTAL HEALTH D VI 445 N SAN JOAQUIN, PHONE (2 3420 ll�� 170 P O BOX 2009, STOCKTON, PERMIT EXPIRES 1 YEAR FROM Complete in Tripli �� L/ Application 1s hereby Dade to San Joaquin County for a permit to construct j1JY t e v / is application is nude in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Ru ea an n Joaquin County Public Health Services. Job Address 805 E Rot h Rd C.tyF r p n c-h C n m¢,ot Size/Acreage Owner's Namd a C.i f 1(. P r e C:a ti_t _.__._• Address 151"19 P e lcft t Rd-- H-.r ;v,a n d _.__. Phone Contractor C l a r k w'C 1 1 _Addressf'l, r r�r L.cense No. 1� �`Phone') 7 6 TYPE OF WELL:'PUMP NEW WELL1@Xx WELL REPLACEMENT 171 DESTRUCTION [' Out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER (; Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK, I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _—_— AGRICULTURE WELL __ OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [1 Industrial O Open Bottom �r Manteca Dia. of Well Excavation_ err Dia of Well Casingrt 1_I Domestic/Private .�j Gravel Pack 7 Tracy Type of Casing__j �gl,,,_ Specifications i'I Public F Other 71 Dara Depth of Grout Seal Type of Grout Q j•g��; I I InifjdUon -__ Approx. Depth I ; Eastern Surface Seal Installed by Repair Work Done U Type of Pump S n h H P. S _ _— State Work Done Well Destruction 71 Well Diameter Sea 11ng Material & Depth tJ/� Depth Filler Material L Depth TYPE OF SEPTIC WORK NEW INSTAI.LATION I I REPAIR:'AOOtTION ' I DES1 RUCTION I I (No septic system permitted if public rower is } available within 200 feet.l 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 _ Cep city_ No. Compartments PKG. TREATMENT PLT.Gl Method of Disposal Distance to nearest: Well .. Foundation =— Property Line LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED n Distance to nearest: Well Founoatron _ Propeny, Line SEEPAGE PITS 11 Depth Size _ Number SUMPS IJ Distance to nearest: Well^ Foundation Property Lime (� DISPOSAL PONDS ❑ I hereby certify that I have prepared this 3ppGcation 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 sign►ture certifies the following: "I unify,that in the performance Of the work foi which this permit is issued, l shall not employ any person in such manner&s to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify thm in the performance of the work for which this permit is issued, I shall employ persocs subject to workman's compansa tion laws of Cafilorrue." The applicanl all f al! r qu d ti C plate drawing on reverse side. Signed Title:VP P C1a1- • Well n c Date: �I 8 O r I y 3 FOR DEPARTMENT USE ONLY Application Accep!etl by Ar , T Pit or Grout Irvpection by DZL61 0'02Z r Final Inspe Date Additional G'omrnents: D m j Ay APcl ic�nl. - Return all coplefi to: San Joaquin County Public Health Sc r'ices�r / V I t Envirunrnental Health permit./Services / 445 N San Joaquin, P U nox 2009, Stkn, CA 95201 Ohn// O \� FEE IT N _ Vl INFO AMOUNT DUE AMOU(N�T R/E�M�,ITTED ASH RECEIVED BY / DATE PERMIT N0. EH U 2a