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APPLICATION i� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES '�ENVIRONkENTAL HEALTH ,DIVISION 445N SAN JOAQUTN; PHONE (209)468-3420 f P,', O BOX ! 2009; STOCKTONy CA 95201 ,I .! i Y° PERM-IT EXPIRES 1- YEAR FROM "DATE ISSUED 'i (Complete in Triplicate) Application is hereby made,to San Joaquin County, for;a permit to construct and/ install the work herein described. This application is made in compliance with San.Joaquin County:Ordinance No. 549 and 1862 and the Rules snd Regulations of San Joaquin County Public Health Services. i ii Job Address 700 W. Linne Road I City TZaCX_�� Lot Size/Acreage 1.25 Robert- Bo e Owner's Name _ _-_-- t t i i Address P•0. Box.797 Vernalis CA �j Pnona 209) 531-3202 �,g f.s u..;�-t �I 6'Z7�� s�o6 s. r �°'_«.e--zv9zS2-�6 p �c Conlrattor dress CRA Li, �fVo, nni nn Phone r TYPE OF WELL/PUMP: NEW WELiL?F WELL REPLACEMENTry El DESTRUCTION (71 Out of Service Well ❑ PUMP INSTALLATION ❑ ISY57EM A1PAIR"❑ OTHER ❑ Monitoring tile)) �! DISTANCE TO NEAREST: SEPTIC TANK 50'' SEWER LINES DISPOSAL FLD. }i PROP. LINE FOUNOATION AGRICULTURE WELL OTHER WELL 5O„ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS � Cl Industrial ❑ Open Bottom ❑ Manteca 'Dia. of Well Excavation Dia. of Well Casing 211 Cl Domestic/Private CR Gravel Pack . C71� Tracy, Type of Casing_ PVC SCh LSO. W -Specifications I') Public Cl Other in Delta"li' i. .I.Depth of Grout Seal 10t Typo of Grout Bentonite_,_ i I Irrigation �Approx. Depth ,�`! I Eastern Ii Surface Seal Installed by I Repair Work Done U Type of Pump H.P:r _ State Work Dona !! Well Destruction Cl' Well Diameter. Sealing Material 6 Depth �� ! ' , Filler Material i Depth' See attached diagram - Depth a�" I + TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted it public sewer is 1 Ik °' available within 200 feet.) Installation will serve: Residence Commercial TOther I Number of living units: Number of bedrooms — F Character of soil to a depth of 3.feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Gl II � Methodiof Disposal j Distance to nearest Well x I�"Foundation Property Line LEACHING LINE ❑ No. & Length of lines F] Total length/size I FILTER BED Cl Distance to nearest:' Well �) Foundation Property Line;I II SEEPAGE PITS 11 Depth Size Number i SUMPS Ll Distance to nearesO Well + Foundation Property Line DISPOSAL PONDS O I hereby certify that I hove 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 It i ! Home owner or licensed agent's signature oenifiesthe 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 i certifies the following: "I certify that in the performbnce of the work for which this permit is issued, I shall employ perwna subject to workman's compensa- tion laws of California." I� The applicant must c II } all r ired ins ions: Complete drawingreverrV sides, I, Signed Title; � l-` ri' }�� y� Date: r k I FOR DEPARTMENT USE ONLY !" Application Accepted by a Data lZ Area Pit or Grout Inspection by � to ! Final Inspection byDate Additional Comments: S l"�/f�P C ( l LI r Applicant - Return all- copies to:. San Joaquin County Public Health Services 4 Environmental Health permit/Services 445 N San Joaquin P O Box 2008; Stkn, CA 95201 0 q J jiFEE . INFO AMOUNT DUE AMOUNT REMITTED 1 CK I CASH RECEIVED By DATE PERMIT"NO, r Page 13A EH 13.2 (REV.i i r sl EH 14-A al ii. -