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i APPLICATION FOR PERMTT L SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOR 2009, STOCKTON, CA 95201 22MIT 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. Job Address 3050 W. Carlin. Rd. City Stockton Lot Size/Acreage Owner's Name Lloyd L. Phelps, Sr. Address 12007 S. Roberts Rd. , Stockton Phone 463-6456 ContractorHennings Bros. Address 3525 Pelandale, Mod. License N,. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 124' SEWER LINES DISPOSAL FLD. 124' 1 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing 611 A Domestic/Private IN Gravel PackL y Type of Casing. PVC Specifications— 60 .scb Il Public 1.1 Other Depth of Grout Seat 20 pYay11 Type of Grout Bentonite I I Irrigation —.Approx. Depth t I Eastern Surface Seal Installed by --- Shallow ter Repair Work Done L3 Type of Pump H.P. State Work Done _ Mable Well Destruction ❑ Wel! Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve' Residence��' Commercial_ Other ' � � 64156 Number of living units: Number of bedrooms Hn'-� npp �zri,�.r 4L„ v _ s pa '�45 1185 Charac[er Of soil to as depth of 3 feet: SEPTIC TANK. Water table depth 0 Type/Mfg. Y Capacity No. Compartments PKG. TREATMENT PLT.C7 Method of Disposal 1 Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No, & Length of lines Total length/size 1 I FILTER BED ❑ Distance to nearest: Well Foundation Property Line ; SEEPAGE PITS 11 Depth Sire Number r SUMPS LI Distance to nearest: Well Foundation Property Line - DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 4 rules and regulations of the San Joaquin County 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 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." The applicant must call for all required inspections. Complete drawing on reverse side. rennin s Bros. Signed g Title: ' data: 6-6-91 FO Sl: ONLY Q Application Accepted by Date "" ` 3)3 Area Pi or Grout I ction by Date / 'not Inspection b Date Additional Comments: 7 , I Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE A OUNT DUE OUNT REMITTED CK RECEIVETE PEA MF BY DA14t17'ND. INF CASH A Q . EH 19.24 IREV.rills y0 0 ^ I[ Lill 742e LJJ t V Mf f